Statement of income distributed by a securitisation trust to be provided to the investor under section 221

Part A: Particulars ofthe Investor

1

.

Name:

(refer Note 1)

2

.

Address:

(refer Note 2)

3

.

Permanent Account Number (PAN):

4

.

E-mail Id:

5

.

Contact Number:

Country

Code

Countr

y Code

6

.

Name of the securitisation trust:

7

.

PAN of the securitisation trust:

Part B: Other Information

8

.

Tax Year:

9

.

Details of the income paid or credited/ deemed to be credited by the securitisation trust to the investor during the tax year:

Sl.

No

.

Amoun

t paid or

credite

d or

deemed

to be

credite d

Date of

paymen

t or credit

or

deemed

to be

credited

Breakup of Amount paid / credited under the Heads of Income

‘Income from

House

Property ‘

‘Business or

profession ‘

‘Long Term Capital Gains‘

‘Short Term

Capital Gains‘

‘Income from other sources‘

Capita

l

Gains

Code

(refer

Note

3)

Amoun

t

Capita

l

Gains

Code

(refer

Note

3)

Amoun

t

‘Dividend ‘

Others (specif

y if

taxed at

special rates)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

1.

2.

(Repeat, if

required)

Verification

I, , hereby declare 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.

Place: Signature:

Date: Name:

Designation:

Sl.

No.

Capital Gains

Code

1.

Long term capital gain chargeable at 12.5% under section 198

1

2.

Long term capital gain chargeable at 12.5% under section other than section 198

2

3.

Long term capital gain chargeable at 20%

3

4.

Short term capital gain chargeable at 20% under section 196

4

5.

Short term capital gain chargeable at 30%

5

6.

Short term capital gain chargeable at applicable rates

6