Statement of income distributed by a business trust to be provided to the unit holder under section 223

Part A: Particulars ofthe Unit Holders

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

E-mail Id:

5.

Contact Number:

Country

Code

Number

6.

Name of the business trust:

7.

PAN of the business trust:

Part B: Other Information

8.

Tax Year:

9.

Details of the income distributed by the business trust to the unit holder, during the tax year, in the following format:

Sl.

No.

Amount

distributed

Date of

distribution

Amount of

income in the

nature of interest

referred to in

Schedule V

[Table: Sl. No. 3(a)]

Amount of

income in the

nature of

renting or

leasing or

letting referred

to in Schedule

V [Table: Sl. No. 4]

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 exercised

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 exercised

option under

section 200

Amount

of

income

other

than that

referred

to in

column

(4), (5),

(6), and

(7)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

1.

2.

(Repeat, if

required)

10.

Details of the amount referred to in section 92(2)(k) distributed by the business trust to the unit holder, in the following format:

Sl.

No.

Number of units

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)

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: