Statement of income paid or credited by Venture Capital Company or Venture Capital Fund to be furnished under section 222

Part A: Particulars ofthe Venture Capital Company or Venture Capital Fund

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

E-mail Id:

5.

Contact Number:

Countr

y Code

Num

ber

Part B: Other Information

6.

Tax Year:

7.

Details of the Directors ofthe Venture Capital Company/ trustees of the Venture Capital Fund:

Sl.

N

o.

Name

PAN

Aadhaar

Address

Contact

Number

E-mail Id

Designation

1.

2.

(Repeat,

if

required

)

8.

Details of registration of the Venture Capital Company or Venture Capital Fund with Securities and Exchange Board of India (SEBI):

Regulations under which registered (SEBI (Venture Capital Funds) Regulations, 1996 or SEBI (Alternative Investment Funds) Regulations, 2012)

Date of

registration

Registration

Number

Validity of

registration (up

to)

9.

In a case where Venture Capital Company or Venture Capital Fund is registered under SEBI (Alternative Investment Fund) Regulations, 2012:

(i)

Whether it has invested two-third or more of its investible funds in unlisted equity shares or equity linked instruments of venture capital undertaking:

Yes/No

(ii)

Whether it has made any investment in any venture capital undertaking in which, -

(a) its director or a substantial shareholder (being a beneficial owner of equity shares exceed- ing ten per cent of its equity share capital); or

(b) its trustee or settler, as the case may be, holds, either individually or collectively, equity shares in excess of fifteen per cent of the paid-up equity share capital of such venture capi- tal undertaking

Yes/No

(iii)

Whether the shares or units of the Venture Capital Company or the Venture Capital Fund are listed on any recognised stock exchange at any time during the tax year:

Yes/No

1

0.

Total income from the investments in Venture Capital Undertakings under the head ‘Capital Gains‘ [A]:

(i)

Long Term Capital Gains:

(a)

(I)

Capital Gains Code (refer Note 3):

(II)

Amount:

(III)

Proportion to [C] (in %):

(b)

(Repeat, if required,for the multiple capital gains code)

(ii)

Short Term Capital Gains:

(a)

(I)

Capital Gains Code (refer Note 3):

(II)

Amount:

(III)

Proportion to [C] (in %):

(b)

(Repeat, if required,for the multiple capital gains code)

1

1.

Total income from the investments in Venture Capital Undertakings under the head ‘Income from other sources‘ [B]:

(i)

(a)

Dividend:

(b)

Proportion to [C] (in %):

(ii)

(a)

Other:

(b)

Proportion to [C] (in %):

1

2.

Total income under all the heads from the investments in Venture Capital Undertakings [C] = [A] + [B]:

13.

Details of persons, referred to in section 222(1) by whom the income is received or in whose name it has been credited or deemed to have been credited, in the following format:

Sl.

No.

Name(s)

of the

investor

Address

(es)

PAN/

Aadh

aar

Total

amoun

t paid/

credite

d/

deeme

d to be

credite

d

Date of

payme

nt/

credit

Income under the head ‘Capital Gains‘

Income under the

head ‘Income from

other sources‘

Long-term Capital Gains

Short-term Capital Gains

Capital

Gains

Code

Income

Capita

l

Gains

Code

Income

Divide

nd

Other

(interest,

etc.)

(1)

(2)

(3)

(4)

(5)

(6)

(7) =

relevan

t codes

at Sl.

No.

10(i)

(8) = (5)

× Sl.

No.

10(i)

(proport

ion to

[C] for

each

capital

gains

code)

(9) =

releva

nt

codes

at Sl.

No.

10(ii)

(10) =

(5) × Sl.

No.

10(ii)

(proporti

on to [C]

for each

capital

gains

code)

(11) =

(5) ×

Sl. No.

11(i)(b)

(12) =

(5) × Sl.

No.

11(ii)(b)

1.

2.

(Repeat, if required,for each name and capital gains code as

well)

1

4.

Other details to be provided as separate enclosure:

(attach as per

Note 4)

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.

Place: Signature:

Date: Name:

Designation:

Verification

I have examined the books of account and other documents showing the particulars of income earned and the income distributed / credited (including amount deemed to have been credited in accordance with provisions of section 222(5)) to the investors by the (name of the Venture Capital Company or the Venture Capital Fund) for the tax year ending .

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

Place: Signature:

Date: Name of the accountant:

Designation:

Membership Number:

UDIN, if any:

Name of the Proprietorship/Firm:

Firm Registration Number:

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 198

4

5.

Short term capital gain chargeable at 30%

5

6.

Short term capital gain chargeable at applicable rates

6

Annexure

. .

Particulars

A-1

A copy of the certificate of registration under Securities and Exchange Board of India Act, 1992 (15 of 1992).

A-2

A copy of the Venture Capital Fund deed in case of Venture Capital Fund registered under the provisions of the Registration Act, 1908 (16 of 1908).

A-3

Audited accounts including balance sheet, annual report, if any, with certified copies of income and appropriation towards distribution of income or credit of income (including amount deemed to have been credited in accordance with provisions of section 222(5)).