Intimation by a designated constituent entity, resident in India, of an international group, for the purposes of section 171(4)

Part A: Particulars of the Designated Constituent Entity

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

Part B: Other Information

6.

Name of the international group of which the assessee is a constituent entity:

(refer Note 1)

7.

Details of the parent entity of the international group:

Name (refer Note 1)

Address (refer Note 2)

Country of residence

8.

Accounting Year for which the report is being submitted:

Verification

I, , hereby affirm that the information provided in this application is true and correct to the best of my knowledge. I have not concealed any relevant fact.

I am submitting this application in my capacity as (designation), holding PAN and I am competent to verify and submit this application.