Information to be provided under section 159(8)

Part A: Particulars ofthe Applicant

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Communication Address in India (if available):

(refer Note 3)

4.

Permanent Account Number (PAN) (if available):

5.

E-mail Id:

6.

Contact Number:

Country Code

Number

Part B: Residential Information

7.

Tax Year:

8.

Status:

(refer Note 4)

9.

Country of residence (in the case of an individual) or Country/Region of incorporation/ registration (in the case of others):

(refer Note 5)

10.

Tax Identification Number (TIN) in country/region of residence:

(refer Note 6)

11.

Period for which the residential status as mentioned in the certificate referred to in section 159(8) is applicable:

12.

Address of the assessee in the country or region outside India during the period for which the certificate, mentioned in Sl. No. 11 above, is applicable:

13.

Copy of the certificate referred to in section 159(8):

Upload the copy as Annexure

Declaration

I (Name of assessee) with (PAN/Unique identification number) have obtained a certificate referred to in section 159(8) from the Government of  (name of country or region outside India) which is provided as per Part B (Sl. No. 13).

Verification

I hereby affirm that the information provided above is true and correct to the best of my knowledge and belief. I have not concealed any relevant fact. I am submitting this form in my capacity as (designation), holding PAN and I am competent to verify and submit this form.

(I)

Individual

(II)

Hindu undivided family

(III)

Company

(IV)

Firm

(V)

Association of Persons or Body of individuals, whether incorporated or not

(VI)

Local authority

(VII)

Artificial Juridical Person

(VIII)

Government

(IX)

Trust

(X)

Limited Liability Partnership