Statement of income paid or credited by investment fund to be furnished under section 224

Part A: Particulars ofthe Investment Fund

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Legal Status:

(refer Note 3)

4.

Permanent Account Number (PAN):

5.

E-mail Id:

6.

Contact Number:

Country Code

Number

Part B: Other Information

7.

Tax Year:

8.

Details of the Directors or Partners or Trustees of the Investment Fund:

Sl.

No.

Name

PAN

Aadhaar

Address

Contact

Number

E-mail Id

Designation

1.

2.

(Repeat, if

required)

9.

Details of registration of the Investment Fund as Alternative Investment Fund:

Regulation under which registered (Securities and Exchange Board of India (Alternative

Investment Funds)

Regulations, 2012 or

International Financial Services Centres

Authority (Fund

Management)

Regulations, 2022)

Whether registered as Category I or

Category II (select as applicable) if

regulated under

Securities and

Exchange Board of India (Alternative Investment Funds) Regulations, 2012

Date of

registration

Registration

Number

Validity of

registration (up to)

10.

Total income of the Investment Fund during the tax year:

11.

Break-up of total income (aggregate of amounts under column (7) should match with the total income provided at Sl. No. 10):

Sl.

No.

Under the head

Income or Loss

Loss to be set

off in

accordance

with section 224(2)

Net Income

or loss after

set off of

losses in

terms of section

Amount

From

Offshore

investment

out of the investment

Net

of non-

resident unit holder

224(2)

(1)

(2)

(3)

(4)

(5) = (3) –

(4)

(6)

(7) = (5) – (6)

1.

Profit and gains of business or

profession

2.

Long Term Capital Gains

3.

Short Term Capital Gains

4.

Income from other

sources (Dividend/

Others) (Specify

section if taxed at

special rates)

12.

Details of losses of the tax year, if any; required to be ignored for the purposes of section 224(2) in accordance with, —

(i)

Section 224(2)(a)(ii):

Head of Income

Amount of loss

Profit and gains of business or profession

(ii)

Section 224(2)(b):

Sl. No.

Head of Income

Amount of loss

1.

2.

(Repeat, if required)

13.

Details of losses under the head ‘Profit and gains of business or profession‘, if any:

Sl.

No.

Details of brought forward loss, if any

Amount of income or

loss during the tax year

after set-off (in

accordance with section

224(2))

Amount of loss to be carried

forward

Tax Year/ Assessment

Year

Amount

Tax Year/

Assessment

Year

Amount

(1)

(2)

(3)

(4)

(5)

(6) = (3) – (4)

1.

2.

(Repeat, if required)

14.

Aggregate of positive income of the Investment Fund under various heads after setting off of losses at Sl. No.

13 (aggregate of the positive amounts in Sl. No. 11 (Column (7) after set off) [API]:

(i)

(a)

Income under the head ‘Profit and gains of business or profession‘:

(b)

Proportion to [API] (in %):

(ii)

Income under the head ‘Capital Gains‘:

(a)

Long Term Capital Gains:

(I)

(A)

Capital Gains Code (refer Note 4):

(B)

Amount:

(C)

Proportion to [API] (in %):

(II)

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

(b)

Short Term Capital Gains:

(I)

(A)

Capital Gains Code (refer Note 4):

(B)

Amount:

(C)

Proportion to [API] (in %):

(II)

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

(iii)

Income under the head ‘Income from other sources‘:

(a)

(I)

Dividend:

(II)

Proportion to [API] (in %):

(b)

(I)

Other (specify section if taxed at special rates):

(II)

Proportion to [API] (in %):

15.

Details of losses other than the loss under the head ‘Profits and Gains of business or profession‘, if any, accumulated at the level of investment fund as on the 31st March, 2019:

Assessment

Year

Amount of Loss under various heads of income

Total

Long Term Capital Loss

Short Term Capital Loss

2016-17

2017-18

2018-19

2019-20

Total

16.

Aggregate of losses under various heads after ignoring the losses at Sl. No. 12(ii) (aggregate of the negative amounts in Sl. No. 11 (Column (7)) [AL]:

(i)

Loss under the head ‘Capital Gains‘:

(a)

Long Term Capital Gains:

(I)

(A)

Capital Gains Code (refer Note 4):

(B)

Amount:

(C)

Proportion to [AL] (in %):

(II)

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

(b)

Short Term Capital Gains:

(I)

(A)

Capital Gains Code (refer Note 4):

(B)

Amount:

(C)

Proportion to [AL] (in %):

(II)

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

(ii)

Loss under the head ‘Income from other sources‘:

(a)

(I)

Other (specify section if taxed at special rates):

(II)

Proportion to [AL] (in %):

17.

Details of person being a unit holder, referred to in section 224(1) by whom the income or loss is received or in whose name it has been credited, in a case where, —

(i)

there is a positive income:

Sl.

N

o.

Nam

e(s)

of

the

unit

hold

er

Addre

ss(es)

PAN

/

Aad

haar

Total

amo

unt

of

posit

ive

inco

me

paid/

credi

ted/

dee

med

to be

credi

ted

Date

of

pay

ment

/

credi

t

Incom

e

under

the

head

‘Profi

t and

Gains

of

busin

ess or

profes

sion‘

Income under the head ‘Capital Gains‘

Income under

the head

‘Income from

other sources‘

Long Term

Capital Gains

Short Term

Capital Gains

Capi

tal

Gain

s

Cod

e

Incom

e

Capi

tal

Gain

s

Cod

e

Incom

e

Divide

nd

Other

(specif

y

section

if

taxed

at

special

rates)

(1)

(2)

(3)

(4)

(5)

(6)

(7) =

(5) ×

Sl.

No.

14(i)(

b)

(8)

=

rele

vant

code

s at

Sl.

No.

14(ii

)(a)

(9) =

(5) ×

Sl.

No.

14(ii)(

a)

(propo

rtion

to

[API]

for

each

capital

gains

code)

(10)

=

rele

vant

code

s at

Sl.

No.

14(ii

)(b)

(11) =

(5) ×

Sl.

No.

14(ii)(

b)

(propo

rtion

to

[API]

for

each

capital

gains

code)

(12) =

(5) ×

Sl. No.

14(iii)(

a)(II)

(13) =

(5) ×

Sl. No.

14(iii)(

b)(II)

1.

2.

(Repeat, if required)

(i

i)

there is a loss in respect of units held for more than 12 months as per section 224(2)(a)(ii):

Sl.

N

o.

Name

(s) of

the

unit

holder

Address(

es)

PAN/

Aadha

ar

Total

amoun

t of

loss

paid/

credite

d/

deeme

d to be

credite

d

Date

of

payme

nt/

credit

Loss under the head ‘Capital Gains‘

Income

under

the head

‘Loss

from

other

sources‘

Long Term

Capital Gains

Short Term

Capital Gains

Capit

al

Gains

Code

Income

Capit

al

Gains

Code

Income

Other

(1)

(2)

(3)

(4)

(5)

(6)

(7) =

releva

nt

codes

at Sl.

No.

16(i)(

a)

(8) = (5)

× Sl.

No.

16(i)(a)

(proporti

on to

[AL] for

each

capital

gains

code)

(9) =

releva

nt

codes

at Sl.

No.

16(i)(

b)

(10) =

(5) × Sl.

No.

16(i)(b)

(proporti

on to

[AL] for

each

capital

gains

code)

(11) =

(5) × Sl.

No.

16(ii)(a)(

II)

1.

2.

(Repeat, if required)

1

8

.

Other details to be provided as separate enclosure:

(attach as per

Note 5)

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 / credited (including amount deemed to have been credited in accordance with provisions of section 224(7)) to the unit holder by the ( Investment fund) for the tax year ending .

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

Place: Signature:

Date: Name of the accountant:

Designation:

Membership Number:

UDIN, if any:

Name of the Proprietorship/Firm:

Firm Registration Number:

(I)

Company

(II)

Trust

(III)

Limited Liability Partnership

(IV)

Body Corporate

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

Annexure

. .

Particulars

A-1

A copy of the certificate of registration under Securities and Exchange Board of India Act (Alternative Investment Funds) Regulations, 2012 or the International Financial Services Centres Authority (Fund

Management) Regulations, 2022.

A-2

Audited accounts including balance sheet, annual report, if any, with certified copies of income and appropriation towards payment of income or credit of income (including amount deemed to have been credited in accordance with provisions of section 224(7)).