Exercise of option for relief from taxation in income from retirement benefit account maintained in a notified country under section 158 of the Act

PART-A

1

Details of the specified person

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

(iii)

Permanent Account Number

(iv)

Email ID

(v)

Contact Number

Country Code

2.

Tax year in respect of which option is being exercised

yyyy-yy

PART-B

3.

Details of all the specified accounts maintained by the specified person

A.

Details of specified account

(i)

Account number

(ii)

Name of retirement fund

(iii)

Name of notified country (select one)

1. Canada

2. US

3. UK

4. Other, please specify

(iv)

Balance as on last day of the finan- cial year prior to the tax year for which this form is being filled

(v)

Date on which account opened

dd/mm/yyyy

(vi)

Specify how the income from speci- fied account is taxable in the noti- fied country

(select one)

a. Accrual basis

b. Receipt basis

c. Any other basis, please specify

(vii)

Specify the tax year in which the income from specified account is eligible to be withdrawn

yyyy-yy

(viii)

Nature of Income

(select one or more)

a. Salary

b. Interest

c. Dividend

d. Others, please specify

(ix)

Amount of income from the speci- fied account which has already been included in the income of any earlier tax year during which such income accrued as referred to in rule 74(2)(a)

(x)

Specify the tax year or years in which amount referred to in (ix) has been included

Tax year

Amount

of in-

come

Whether

ITR filed

Acknowledgement Number

yyyy-yy

Yes/No

yyyy-yy

Yes/No

(xi)

Amount of Income from the speci- fied account which was not taxable in India due to reasons referred in rule 74(2)(b)

(xii)

Specify the tax year or years in which amount referred to in (xi) is exempt on account of the specified person being "non-resident" or "not ordinarily resident"

Sl.No

Tax

year

Amount of income

(a)

yyyy-yy

(b)

yyyy-yy

B.

Repeat if required

4.

Details of option being exercised —

The income accrued in specified accounts as specified in row 3 above, shall be includ- ed in the total income for the tax year in which income from the said specified ac- count has been taxed or taxable in the noti- fied country at the time of withdrawal or redemption

(select one)

1. Yes

2. No

5.

Other details to be provided as separate enclosure:

Attach as per note 4

Declaration

I (name) holding Permanent Account Number hereby declare that I have exercised the option for all the specified accounts mentioned in row 3 above. I understand that the said option, once exercised for any tax year, cannot be withdrawn for this tax year or any subsequent year. I do hereby declare that the in- formation given above is correct and complete to the best of my knowledge and belief and is in accordance with the provisions of the Act.

Place:

Date:

Signature

Name

Annexure

Particulars

A-1

A copy of statement of the specified account having following details-

i. the account number of all the specified accounts;

ii. the notified country in which such account has been opened; and

iii. the balance in the specified account as on last date of the financial year prior to the tax year for which this Form No. 40 is submitted.

A-2

Documentary evidence to show how the income from specified account has been taxed or is taxable in the notified country. Relevant statutory provision of the notified country or any other relevant document

may be attached.

A-3

The computation of income for all the tax years [as per row No. 3(ix)] in which the income from spec- ified account has already been included in the total income. The computation has to be reconciled with the return of income for the said tax years.

A reconciliation statement of the computation of income [as per row No. 3(ix)] has to be furnished along with the form.