Form of application for an assessee, resident in India, seeking to invoke mutual agreement procedure provided for in agreements with other countries or specified territories

Part A: Particulars ofthe Applicant

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

Email Id:

5.

Contact Number:

Country

Code

Number

Part B: Other Details

6.

Status:

(refer Note 3)

7.

Tax Year(s):

8.

Jurisdictional Circle/ Ward:

9.

Name and Designation of Tax Authority in the other country or region (Treaty Partner):

10.

Date of the notice or order giving rise to the action:

11.

Whether it is claimed that the order/action of the Tax Authority of the Treaty Partner not in accordance with the agreement? (refer Note 5.A-3)

Yes/No

12.

Other details to be provided as separate enclosure:

(refer Note 4)

Verification

I, , solemnly affirm that to the best of my knowledge and belief, the information given in this application and the annexures and statements accompanying it is correct and complete and particulars shown therein are truly stated.

I also declare that to the best of my knowledge, I have not concealed any fact or information which could be relevant for deciding my application.

I further declare that I am making this application in my capacity as (designation) and that I am holding PAN and I am competent to make this application and verify it.

(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

Annexure

Particulars

A-1

Copy of notice or order giving rise to action.

A-2

Detailed reasons provided in respect of Part B (Sl. No. 11), if any.

A-3

If answer is ‘Yes‘ in Part B (Sl. No. 11), then complete details along with reasons thereof must be provided.

A-4

Details of remedy sought in the other country or specified territory, if any, with documentary evidence.

A-5

Document(s) in respect of A-4.

A-6

Any other document