Statement of income from a country or region outside India and Foreign Tax Credit

Part A: Particulars ofthe Person

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

E-mail Id:

5.

Contact Number:

Country

Code

Number

6.

Tax Year:

Part B: Other Information

Details of income from a country or region outside India which is offered to tax or assessed to tax in India and on which Foreign Tax Credit is claimed:

S

l.

N

o.

Na

me of the

cou

ntry /

regi

on

(see

Not

e 3)

Taxpa yer

Identif

ication

Numb er

(TIN)

(see Note 4)

Sourc

e of

incom e

Inc

om e

fro m out

side

Indi a

Income-

tax paid outside

India

Tax

pay

able

on

suc h

in-

com e

un-

der

the

In-

com e-

tax

Act,

202

5

(re-

fer

Not

e 6)

Details of foreign tax credit under section 159

Am

oun

t of

for-

eig n tax

cre dit un-

der

sec-

tion

160

Whet her

amou

nt in

colu mn (11) or

(12) or

any part there

of is

under

dispu te?

If

‘Yes

‘ in

colu

mn

(13)

,

amo

unt of suc h

disp

uted

fore

ign

tax

cred it

Tota l

forei gn

tax cred it

[(15

) =

(11+

12)]

Tot al

fore

ign

tax

cre dit clai

me d

[(16

) =

(15)

-

(14)

]

Am

oun t

R

at

e

Articl e

Numb

er of

Doubl e

Taxati on

Avoid ance Agree

ments

(refer Note 7)

Rate

of tax

as per

Doubl e

Taxati on

Avoid ance Agree

ments

(refer

Note

8)

Am

oun t

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

(15)

(16)

Salary

House

prope

rty

Busin

ess or

profes

sional

Long

term

capita

l gain

Short

term

capita

l gain

Intere

st

(refer

Note

5)

Divid

end

(refer

Note

5)

Royalt

y

(refer

Note

5)

Fees

for

techni

cal

servic

es or

fee for

includ

ing

servic

es

(refer

Note

5)

Other

s

(speci

fy)

Part C: Details regarding refund of foreign tax by foreign tax authority for which credit was already claimed

in India

Whether carry backward of loss of current year or revision of Income Tax Return (ITR)/Income Tax

Declaration (ITC) of any year(s) or any other reason has led to refund of foreign tax by foreign tax authority for which credit was already claimed in India in any tax year(s)?

Yes

/No

If reply to the above is Yes,

Reason

Amount of the

Amount of the foreign

Tax Year(s) in which

please furnish these details:

for refund

of the

foreign

tax

refund of the

foreign tax

tax out of amount in

column (2) for which

credit was already

claimed in India

credit of the amount

mentioned in column

(3) was claimed in

India

(1)

(2)

(3)

(4)

Declaration and verification

I, , hereby declare that the information provided above is true and correct to the best of my knowledge. I have not concealed any relevant fact. I confirm that the amount of Foreign Tax Credit claimed by  (name of the taxpayer) for the tax year is in accordance with the applicable Double Taxation Avoidance Agreement(s) and relevant provisions of the Income-tax Act, 2025 and Income-tax Rules, 2026 I am submitting this form in my capacity as (Designation), holding PAN and I am competent to submit this form.

Digital signature: Date:

Place:

Verification by an accountant

I holding PAN have examined the books of account and other documents showing the particulars of income from a country or region outside India and evidence of Foreign Tax paid thereon by the (name of the assessee) for the tax year  . The amount of Foreign Tax Credit claimed by (name of the assessee) for the tax year in Part B and/or the details furnished in Part C of this form are in accordance with the applicable Double Taxation Avoidance Agreement(s) and relevant provisions of the Income-tax Act, 2025 (30 of 2025) and Income-tax Rules, 2026.

I affirm that the above particulars are true and correct to the best of my/our knowledge and belief.

Place: Signature:

Date: Name of the accountant:

Designation:

Membership Number:

UDIN, if any: Name of the Proprietorship/Firm:

Firm Registration Number: