Statement of income distributed by an investment fund to be provided to the unit holder under section 224

Part A: Particulars ofthe Unit Holder

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 Investment Fund:

7.

PAN of the Investment Fund:

Part B: Other Information

8.

Tax Year:

9.

Details of the income or loss (after ignoring the loss under 224(2)(b)) paid or credited/deemed to be credited by the Investment Fund to the unit holder during the tax year:

Sl.

No.

Amount paid or credited

Date of

payment

or credit

Breakup of Amount paid / credited under Heads of Income

‘Business or

profession‘

‘Long Term

Capital Gains‘

‘Short Term

Capital Gains‘

‘Dividend‘

Others

(specify

if taxed at

special rates)

Capital

Gains

Code

(refer

Note 3)

Income

or Loss

Capital

Gains

Code

(refer

Note 3)

Income

or Loss

Income

Income

Income

or Loss

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

1.

2.

(Repeat, if required)

10.

Details of deemed loss as on 31st March,2019 in terms of section 224(3) (to be passed to the unit holder holding unit on 31st March, 2019):

Sl.

No.

Tax Year

Breakup of deemed loss under Head of Income

‘Long Term Capital Gains‘

‘Short Term Capital Gains‘

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:

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