Quarterly statement to be furnished by specified fund or stock broker in respect of a non-resident referred to in rule 157 for the quarter of of (Financial Year)

Part A: Particulars ofthe Specified Fund/Stock Broker

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

Category (Specified Fund/ Stock Broker)

5.

E-mail Id:

6.

Contact Number:

Country

Code

Number

7.

Other details to be provided as separate enclosure:

(attach as per

Note 3)

Part B: Details of non-resident referred to in rule 157(1) or (3)

Sl.

No.

Name (refer

Note 1)

E-mail Id

Contact

number

Address in

the Country

or region

outside In-

dia of which

the non- res-

ident is res-

ident (refer Note 2)

Tax Identifi-

cation Num-

ber, if any

Unique Number on the basis of which the non- resident is identified by the Government of that country or the specified territory of which he claims to be a resident (to be furnished if Tax Identification Number is not available)

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.

An-

nex-

ure

Particulars

A-1

Declaration received from the non-resident as referred to in rule 157(1)(c)(iii) or (3)(b)(iii)].