Statement of income paid or credited by business trust to be furnished under section 223

Part A: Particulars ofthe Business Trust

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

E-mail Id:

5.

Contact Number:

Count

ry

Code

Num

ber

Part B: Other Information

6.

Tax Year:

7.

Details of the trustees of the business trust:

Sl

.

N

o.

Name

PAN

Aadhaar

Address

Contact

Number

E-

mail

Id

Designation

1.

2.

(Repeat, if required)

8.

Details of registration of the business trust with Securities and Exchange Board of India (SEBI):

Regulations under which registered (SEBI (Real Estate Investment Trusts) Regulations, 2014 or SEBI (Infrastructure

Investment Trusts) Regulations, 2014)

Date of

registration

Registration

Number

Validity

of

registrati

on (up

to)

9.

Whether the units of the business trust are listed on any recognised stock exchange at any time during the tax year:

Yes/No

1

0.

(i)

Income by way of interest referred to in Schedule V [Table: Sl. No. 3(a)] [A]:

(ii)

Proportion to [F] (in %):

1

1.

(i)

Income by way of renting or leasing or letting referred to in Schedule V [Table: Sl. No. 4] [B]:

(ii)

Proportion to [F] (in %):

1

2.

(i)

Income by way of dividend referred to in Schedule V [Table: Sl. No. 3(b)] in a case where the special purpose vehicle has exercised option under section 200 [C]:

(ii)

Proportion to [F] (in %):

1

3.

(i)

Income by way of dividend referred to in Schedule V [Table: Sl. No. 3(b)] in a case where the special purpose vehicle has not exercised option under section 200 [D]:

(ii)

Proportion to [F] (in %):

1

4.

(i)

Income other than referred to in Sl. Nos. 10, 11, 12 and 13 [E]:

(ii)

Proportion to [F] (in %):

1

5.

Aggregate income of the business trust from all sources [F] = [A] + [B] + [C] + [D] + [E]:

16.

Details of persons being unit holders, referred to in section 223(1) to whom the income is distributed, in the following format:

Sl.

No.

Name(

s)

Address

(es)

PAN/

Aadha

ar

Total

amount

distribut

ed

Date of

distributio

n

Amount

of income

in the

nature of interest

referred

to in

Schedule

V [Table:

Sl. No. 3(a)]

Amoun

t of

income

in the nature of

renting or

leasing or

letting referre

d to in

Schedu

le V

[Table:

Sl. No. 4]

Amoun

t of

income

in the nature of

dividen d

referre

d to in

Schedu

le V

[Table:

Sl. No.

3(b)] in

a case where the

special

purpos e

vehicle has

exercis ed

option under section 200

Amount

of

income

in the

nature of

dividend

referred

to in

Schedule

V

[Table:

Sl. No.

3(b)] in a

case

where

the

special

purpose

vehicle

has not

exercise

d option

under

section

200

Amo

unt

of

inco

me

other

than

referr

ed to

in Sl.

Nos.

10,

11,

12

and

13

(1)

(2)

(3)

(4)

(5)

(6)

(7) = (5)

× Sl. No.

10(ii)

(8) =

(5) ×

Sl. No.

11(ii)

(9) =

(5) ×

Sl. No.

12(ii)

(10) =

(5) × Sl.

No.

13(ii)

(11)

= (5)

× Sl.

No.

14(ii)

1

7.

Amount distributed by the business trust to unit holders with respect to units as referred to in section 92(2)(k) during the tax year or during any earlier tax year(s), in the following format:

Sl. No.

Tax Year

Number of units

Aggregate amount as

referred to in section

92(2)(k) distributed with

respect to such units during such tax year

1.

2.

(Repeat, if required)

1

8.

Details of persons being unit holders, referred to in section 223 to whom the amount referred to in Sl. No. 17 is distributed, in the following format:

Sl. No.

Name(s)

Address(es)

PAN/Aadhaar

N

u

m

be

r

of

u

ni

ts

Amount as

referred to in section

92(2)(k)

distributed

with respect

to one unit

of unit

holder

during the tax year

Aggregate

amount as

referred to in section

92(2)(k)

distributed

with respect to

all units of

unit holder

during the tax year

1.

2.

(Repeat, if required)

1

9.

Other details to be provided as separate enclosure:

(attach as

per Note 3)

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:

Verification

I have examined the books of account and other documents showing the particulars of income earned and the income distributed to the unit holders by the (name of the Business trust) 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:

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 trust deed 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.