Statement of exempt income under Schedule VI [Table: Sl. Nos. 1 to 4]

Part A: Particulars ofthe Specified Fund

1.

Name:

(refer Note 1)

2.

Address of the registered office:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

Status:

(refer Note 3)

5.

E-mail Id:

6.

Contact Number:

Country

Code

Number

7.

Registration Number as per the certificate of registration issued by the International Financial Services Centre Authority:

8.

Date of registration:

Part B: Other Information

9.

Tax Year:

10.

Total income during the Tax Year:

11.

Details of exempt income under Schedule VI [Sl. No. 1 to 4]:

Sl.

No.

Nature of income of the Specified Fund

Total Income

Income attributable to units held by non- resident (not being a permanent establishment of a non- resident in India)

A

Income as a result of transfer of a capital asset referred to in section 70(1)(r) of the Act

Total of Column (5) in Part I of Annexure A-1 (refer Note 4)

Total of Column (9) in Part I of Annexure A-1 (refer Note 4)

B

Income as a result of transfer of securities (other than shares in a company resident in India)

Total of Column (5) in Part II of Annexure A- 1 (refer Note 4)

Total of Column (9) in Part II of Annexure A-1 (refer Note 4)

C

Income from securities issued by a non- resident (not being a permanent establishment of a non- resident in India) and where such income otherwise does not accrue or arise in India

Total of Column (5) in Part I of Annexure A-2 (refer Note 4)

Total of Column (9) in Part I of Annexure A-2 (refer Note 4)

D

Income from a securitisation trust which is chargeable under the head "Profits and gains of business or profession"

Total of Column (5) in Part II of Annexure A- 2 (refer Note 4)

Total of Column (9) in Part II of Annexure A-2 (refer Note 4)

Total Exempt Income under Schedule VI [Sl. No. 1 to 4]

12.

Whether conditions under rule 144(1) are fulfilled:

Yes/No

13.

Details of units held by residents during the tax year

Sl.

No.

Name of resident

unit

holder

PAN of resident

Tax

Identification

Number in

country of residence

during the tax

year when

unit was

issued

Total

Number

of units held

Value of units

held

Whether

sponsor or

manager

(Yes/No)

Whether

the resident

has become

a resident under

section 6 of

the Act

during this

tax year

subsequent

to the tax

year in

which such

unit or units were

issued? (Yes/No)

If yes

date of exit

from fund

1.

2.

(Repeat, if

required)

Total

14.

Aggregate value of units (₹ in crore) during the tax year:

15.

Aggregate number of units during the tax year:

16.

Proportion of units (value) held by residents during the tax year:

17.

Proportion of units (number) held by residents during the tax year:

18.

Other details to be provided as separate enclosure:

(attach as per Note 4)

Verification

I, (Name in full) having PAN do hereby declare that to the best of my knowledge and belief what is stated above and, in the Annexure(s), including the documents accompanying such Annexure(s), is correct and complete.

2. I do hereby affirm that the conditions stipulated in Schedule VI [Note 1(g)(i)] are satisfied by the specified fund.

3. I also affirm that during the tax year , the units held by residents are not counted as units held by non- residents, for the purposes of computation of exempt income under rule 139(1) and rule 140(1) and (2).

4. I further affirm that I am furnishing such statement in my capacity as (designation) and that I am competent to make this declaration and furnish this statement.

(I)

Company

(II)

Trust

(III)

Limited Liability Partnership

(IV)

Body Corporate

Ann

exu

re

. .

Particulars

A-1

Sl.

No.

Name of

security

Date of

acquisi tion

Date of

transfer

Capital

Gains

Aggregate of daily

‘assets

under

Manageme nt‘ of the

Specified Fund held by non-

resident

unit

holders

(not being the

permanent

establishm ent ofa

non-

resident in

India) from

the date of

acquisition of the

capital

asset or

security to

the date of

transfer of such

capital asset or security

Aggregate of daily

total

‘assets

under

Manageme nt‘ of the

Specified

Fund from

the date of

acquisition of the

capital

asset or

security to

the date of

transfer of such

capital asset or security

Ratio

Income

attributable to units

held by the non-

resident

(not being the

permanent

establishm ent ofa

non-

resident in India)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

=

(6) /

(7)

(9) = (5) ×

(8)

Part I. Income from transfer of securities referred to in section 70(1)(r)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8) =

(6) /

(7)

(9) = (5) × (8)

1.

2.

(Repeat, if

required)

Tota

l

Part II. Income from Transfer of securities (other than shares in a company resident in India)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8) =

(6) /

(7)

(9) = (5) × (8)

1.

2.

(Repeat, if

required)

Tota l

A-2

Sl.

No.

Name of

security

Nature of

income (refer Note 5)

Date of

receipt of

income

Income

Assets

under

Manageme

nt held by non-

resident

unit

holders

(not being the

permanent

establishm ent ofa

non-

resident in India) as

on the date

of receipt

of income

Total ‘asset under

manageme nt‘ as on

the date of receipt of income

Rati o

Income

attributable to units

held by the non-

resident

(not being the

permanent

establishm ent ofa

non-

resident in India)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

=

(6) /

(7)

(9) = (5) ×

(8)

Part I. Income from Securities attributable to units held by a non-resident (not being a permanent establishment of a non- resident in India) and where such income otherwise does not accrue or arise in India.

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8) =

(6) /

(7)

(9) = (5) × (8)

1.

2.

(Repeat, if

required)

Tota

l

Part II. Income from a securitization trust which is chargeable under the head "Profits and gains of business or profession” .

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8) =

(6) /

(7)

(9) = (5) × (8)

1.

2.

(Repeat, if

required)

Tota l

Sl. No.

Nature of income

Code

1.

Dividend

1

2.

Interest

2

3.

Other Income. Specify

3