Statement of income paid or credited by Venture Capital Company or Venture Capital Fund to be provided to the person who is liable to tax under section 222

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

Country

Code

6.

Name of the Venture Capital Company or Venture Capital Fund:

7.

PAN of the Venture Capital Company or Venture Capital Fund:

Part B: Other Information

8.

Tax Year:

9.

Details of the income paid or credited/ deemed to be credited by the Venture Capital Company or Venture Capital Fund to the investor during the tax year:

Sl.

No.

Amount

paid or credited

or deemed

to be credited

Date of payment

or credit

or deemed

to be credited

Breakup of Amount paid / credited under the Heads of Income

‘Long Term Capital Gains‘

‘Short Term Capital Gains‘

‘Income from other sources‘

Capital

Gains

Code

(refer

Note 3)

Amount

Capital

Gains Code

(refer Note

3)

Amount

‘Dividend‘

Others(interest, etc.)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

1.

2.

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

Declaration

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 198

4

5.

Short term capital gain chargeable at 30%

5

6.

Short term capital gain chargeable at applicable rates

6