Statement containing particulars of declaration received in Form No. 97

PART A: STATEMENT DETAILS

(This information should be provided for each statement submitted together)

A.1

REPORTING PERSON DETAILS

A.1.1

Reporting Person Name

A.1.2

Income-tax Department Report- ing Entity Identification Num- ber

A.2

STATEMENT DETAILS

A.2.1

Statement Type

Insert 2-character code

A.2.2

Original Statement Id

A.2.3

Reason for Correction

Insert 1 character code

A.2.4

Statement Date

A.2.5

Reporting Period

A.2.6

Number of Reports

A.3

PRINCIPAL OFFICER DETAILS

A.3.1

Name

A.3.2

Designation

A.3.3

Address

A.3.4

City / Town

A.3.5

Postal Code

A.3.6

State Code

Insert 2-character code

A.3.7

Country Code

Insert 2-character code

A.3.8

Telephone

A.3.9

Mobile

A.3.10

Email

PART B: REPORT DETAILS FOR FINANCIAL TRANSACTIONS

B.1

REPORT NUMBER (To be provided for each person being reported)

B.1.1

Report Serial Number

B.1.2

Original Report Serial Number

B.2

PERSON DETAILS

B.2.1

Name of the Person

B.2.2

Date ofbirth or Incorporation

B.2.3

Father's Name (for individual)

B.2.4

PAN Application Acknowledgement Number (if applied for PAN and not yet generated)

B.2.5

Aadhaar Number

B.2.6

House no. or Flat no.

B.2.7

Plot No. or Name of Premise or Building

B.2.8

Road or Street or Lane

B.2.9

Area or Locality or Ward or Sector or Taluka or Sub – Division

B.2.10

Town or City or Villageor Post office

B.2.11

District

B.2.12

PIN

B.2.13

State or Union Territory Code

Insert 2-character code

B.2.14

Country Code

Insert 2-character code

B.2.15

Mobile

B.2.16

Telephone Number

B.2.17

Email ID

B.2.18

Taxpayer Identification Number in the coun- try of residence (if covered by rule 159(2)(c) for a foreign company)

B.2.19

Income chargeable to Tax (for a foreign com- pany)

B.2.20

Income not chargeable to Tax (for a foreign company)

B.2.21

Remarks

B.3

FINANCIAL TRANSACTION SUMMARY

B.3.1

Transaction Date

B.3.2

Transaction ID

B.3.3

Transaction Type

Insert 2-character code

B.3.4

Transaction Amount

B.3.5

Cash amount involved in transaction amount

B.3.6

Transaction Mode

Insert 2-character code

B 3.7

In case transaction is in joint name

B 3.8

Number of persons involved in the transac- tion

B 3.9

Share of declarant (in percent)

B.4

Details of Document produced by the person

B.4.1

Identity Proof

B.4.1.1

Document Code

Insert 2-digit code

B.4.1.2

Document Identification Number

B.4.1.3

Name of the authority issuing document

B.4.1.4

Address of the authority issuing document

B.4.2

Address Proof

B.4.2.1

Document Code

Insert 2-digit code

B.4.2.2

Document Identification Number

B.4.2.3

Name of the authority issuing document

B.4.2.4

Address of the authority issuing document

B.4.3

Date ofBirth or Date of Incorporation Proof

B.4.3.1

Document Code

Insert 2-digit code

B.4.3.2

Document Identification Number

B.4.3.3

Name of the authority issuing document

B.4.3.4

Address of the authority issuing document