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INDEX OF DOCUMENTS
MANDATORY DOCUMENTS AS PRESCRIBED BY SEBI & EXCHANGES
S.No. Name of the Document Brief Significance of the Document Page No.
1. KYC (Account Opening) KYC form - Document captures the basic information about the constitute and an 1-3
Application Form instruction / check list.
2. Uniform Risk Disclosure Documents detailing Risk associated with dealing in the Commodities Market. By Email
Document (RDD)
3. Rights and Obligations of Document stating the Rights & Obligation of Member, Authorized Person and client for Trading on exchanges
Members, AP and Clients (including additional Rights and Obligations in case of Internet/Wireless Technology based Trading) By Email
4. Do's and Don'ts for the Document detailing Do's & Don'ts for Trading on exchange, for the education for the investors. By Email
Investors
5. Policies & Procedures Policies and procedures as per Exchange. By Email
6. Other Details Past Action, Dealing Through Other Member, Introducer Details etc. 4-6
7. Tariff Sheet Document detailing the rate/amount of brokerage and other charges levied on the client for 7-7
trading on the Commodity Exchange & Intimation for Proprietary Trading.
For any grievance/dispute please contact Finvasia Securities Private Limited at the above mention address or email
[email protected] . In case not satisfied with response, Please contact the concern exchange(s) at :
Exchange Name E-mail Id Phone No.
Multi Commodity Exchange of India Ltd. [email protected] 022-67318888
National Commodity & Derivatives Exchange Ltd. [email protected] 022-66406789
FINVASIA SECURITIES PVT. LTD.
FINVASIA CENTRE, D 179, Phase 8 B, (Sector 74)
Mohali, Punjab 160055, (India)
SEBI Regn. No. : INZ000176037, Member ID : 55135 (MCX), 01259 (NCDEX)
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual
Important Instructions: E) List of State / U.T code as per Indian Motor Vehicle Act, 1988 is available at the end.
A) Fields marked with ‘*’ are mandatory fields. F) List of two character ISO 3166 country codes is available at the end.
B) Please fill the form in English and in BLOCK letters. G) KYC number of applicant is mandatory for update application.
C) Please fill the date in DD-MM-YYYY format. H) For particular section update, please tick ( ) in the box available before the
D) Please read section wise detailed guidelines / instructions at the end. section number and strike off the sections not required to be updated.
For office use only Application Type* ✘ New Modification
(To be filled by financial institution)
KYC Number (Mandatory for KYC update request)
KYC Type* Normal EKYC OTP Online KYC Digilocker
B- Voter ID Card
C- PAN Card
D- Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar)
F- NREGA Job Card
Z- Others (any document notified by the central government) Identification Number
S- Simplified Measures Account - Document Type code Identification Number
4. PROOF OF ADDRESS (PoA)*
4.1 CURRENT / PERMANENT / OVERSEAS ADDRESS DETAILS (Please see instruction D at the end)
(Certified copy of any one of the following Proof of Address [PoA] needs to be submitted)
(1)
4.2 CORRESPONDENCE / LOCAL ADDRESS DETAILS * (Please see instruction E at the end)
Same as Current / Permanent / Overseas Address details (In case of multiple correspondence / local addresses, please fill ‘Annexure A1’)
Line 1*
Line 2
Line 3 City / Town / Village*
District* Pin / Post Code* State / U.T Code* ISO 3166 Country Code*
4.3 ADDRESS IN THE JURISDICTION DETAILS WHERE APPLICANT IS RESIDENT OUTSIDE INDIA FOR TAX PURPOSES* (Applicable if section 2 is ticked)
Same as Current / Permanent / Overseas Address details Same as Correspondence / Local Address details
Line 1*
Line 2
Line 3 City / Town / Village*
State* ZIP / Post Code* ISO 3166 Country Code*
5. CONTACT DETAILS (All communications will be sent on provided Mobile no. / Email-ID) (Please refer instruction F at the end)
Tel. (Off) Tel. (Res) Mobile
FAX Email ID
6. DETAILS OF RELATED PERSON (In case of additional related persons, please fill ‘Annexure B1’ ) (please refer instruction G at the end)
Addition of Related Person 01-12-2023
Deletion of Related Person KYC Number of Related Person (if available*)
Related Person Type* Guardian of Minor Assignee Authorized Representative
Prefix KRA
First NameVERIFIED Middle Name Last Name
Name*
ANVPG3853B
(If KYC number and name are provided, below details of section 6 are optional)
PROOF OF IDENTITY [PoI] OF RELATED PERSON* (Please see instruction (H) at the end)
GANESH GAWAKHARE
A- Passport Number Passport Expiry Date D D M M Y Y Y Y
B- Voter ID Card
C- PAN Card
D- Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar)
F- NREGA Job Card
Z- Others (any document notified by the central government) Identification Number
S- Simplified Measures Account - Document Type code Identification Number
eSigned using Aadhaar
(Leegality.com - QYIq3p6)
7. APPLICANT DECLARATION GANESH GAWAKHARE
Applicant Wet Signature Applicant e-SIGN
i/we hereby declare that the kyc details furnished by me are true and correct to the best of my/our Date: Sat Dec 02 13:08:13 IST
2023
knowledge and belief and i/we under-take to inform you of any changes therein, immediately. in case
any of the above information is found to be false or untrue or misleading or misrepresenting, i am/we
are aware that i/we may be held liable for it. i/we hereby consent to receiving information from cvl kra
through sms/email on the above registered number/email address. i am/we are also aware that for
aadhaar ovd based kyc, my kyc request shall be validated against aadhaar details. i/we hereby consent
to sharing my/our masked aadhaar card with readable qr code or my aadhaar xml/digilocker xml file,
along with passcode and as applicable, with kra and other intermediaries with whom i have a business
relationship for kyc purposes only.
Date : D D M M Y Y Y Y Place :
8. ATTESTATION / FOR OFFICE USE ONLY Self certified document copies received (OVD)
Documents Received Certified Copies IPV Done ✔ True Copies of documents received (Attested)
[Institution Stamp]
[Employee Signature]
(2)
A. IMPORTANT POINTS: 2. Utility bills like Telephone Bill (only land line), Electricity bill or
1. Self attested copy of PAN card is mandatory for all clients. Gas bill - Not more than 3 months old.
2. Copies of all the documents submitted by the applicant should be 3. Bank Account Statement/Passbook - Not more than 3 months
self-attested and accompanied by originals for verification. In old.
case the original of any document is not produced for verification,
4. Self-declaration by High Court and Supreme Court judges, giving
then the copies should be properly attested by entities
the new address in respect of their own accounts.
authorized for attesting the documents, as per the below
mentioned list. 5. Proof of address issued by any of the following: Bank Managers
3. If any proof of identity or address is in a foreign language, then of Scheduled Commercial Banks/Scheduled Co-Operative
translation into English is required. Bank/Multinational Foreign Banks/Gazetted Officer/Notary
4. Name & address of the applicant mentioned on the KYC form, public/Elected representatives to the Legislative Assembly/
should match with the documentary proof submitted. Parliament/Documents issued by any Govt. or Statutory
5. If correspondence & permanent address are different, then Authority.
proofs for both have to be submitted. 6. Identity card/document with address, issued by any of the
6. Sole proprietor must make the application in his individual name following: Central/State Government and its Departments,
& capacity. Statutory/Regulatory Authorities, Public Sector Undertakings,
7. For non-residents and foreign nationals, (allowed to trade Scheduled Commercial Banks, Public Financial Institutions,
subject to RBI and FEMA guidelines), copy of passport/PIO Colleges affiliated to Universities and Professional Bodies such
Card/OCI Card and overseas address proof is mandatory. as ICAI, ICWAI, ICSI, Bar Council etc., to their Members.
8. For foreign entities, CIN is optional; and in the absence of DIN no. 7. For FII/sub account Power of Attorney given by FII/sub account
for the directors, their passport copy should be given. to the Custodians (which are duly notarized and/or apostiled or
9. In case of Merchant Navy NRI's, Mariner's declaration or certified consularised) that gives the registered address should be taken.
copy of CDC (Continuous Discharge Certificate) is to be
8. The proof of address in the name of the spouse may be
submitted.
accepted.
10. For opening an account with Depository Participant or Mutual
Fund, for a minor, photocopy of the School Leaving D. Exemptions/clarifications to PAN
Certificate/Mark Sheet issued by Higher Secondary (*Sufficient documentary evidence in support of such claims to
Board/Passport of Minor/Birth Certificate must be provided. be collected.)
11. Politically Exposed Persons (PEP) are defined as individuals 1. In case of transactions undertaken on behalf of Central
who are or have been entrusted with prominent public functions Government and/or State Government and by officials appointed
in a foreign country, e.g., Heads of States or of Governments, by Courts e.g. Official liquidator, Court receiver etc.
senior politicians, senior Government/judicial/ military officers, 2. Investors residing in the state of Sikkim.
senior executives of state owned corporations, important political
party officials, etc. 3. UN entities/multilateral agencies exempt from paying taxes/filing
B. Proof of Identity (POI) : - List of documents admissible as tax returns in India.
Proof of Identity: 4. SIP of Mutual Funds upto Rs 50, 000/- p.a.
1. PAN card with photograph. This is mandatory requirement for all 5. In case of institutional clients, namely, FIIs, MFs, VCFs, FVCIs,
applicants except those who are specifically exempt from Scheduled Commercial Banks, Multilateral and Bilateral
obtaining PAN (listed in Section D) Development Financial Institutions, State Industrial
2. Unique Identification Number (UID) (Aadhaar)/ Passport/ Voter Development Corporations, Insurance Companies registered
ID card/ Driving license. with IRDA and Public Financial Institution as defined under
3. Identity card/ document with applicant's Photo, issued by any of section 4A of the Companies Act, 1956, Custodians shall verify
the following: Central/State Government and its Departments, the PAN card details with the original PAN card and provide duly
Statutory/Regulatory Authorities, Public Sector Undertakings, certified copies of such verified PAN details to the intermediary.
Scheduled Commercial Banks, Public Financial Institutions,
E. List of people authorized to attest the documents:
Colleges affiliated to Universities, Professional Bodies such as
ICAI, ICWAI, ICSI, Bar Council etc., to their Members; and Credit 1. Notary Public, Gazetted Officer, Manager of a Scheduled
cards/Debit cards issued by Banks. Commercial/ Co-operative Bank or Multinational Foreign Banks
C. Proof of Address (POA): - List of documents admissible as (Name, Designation & Seal should be affixed on the copy).
Proof of Address: (*Documents having an expiry date 2. In case of NRIs, authorized officials of overseas branches of
should be valid on the date of submission.) Scheduled Commercial Banks registered in India, Notary Public,
1. Passport/ Voters Identity Card/ Ration Card/ Registered Lease or Court Magistrate, Judge, Indian Embassy /Consulate General in
Sale Agreement of Residence/ Driving License/ Flat the country where the client resides are permitted to attest the
Maintenance bill/ Insurance Copy. documents.
(3)
TRADING ACCOUNT RELATED DETAILS (For Individuals)
A. OTHER DETAILS
Gross Annual Income Income Range per annum : Below Rs. 1 Lac ✔ Rs. 1 Lac to 5 Lac
Details (please specify) Rs. 5 Lac to 10 Lac Rs. 10 Lac to 25 Lac >25 Lac OR
Bank Name Branch Address Bank Account Number Account Type MICR Number IFSC Code
PLT NO JP-15 J BLOCK MIDC
ICICI BANK LTD TELCO BHOSARI ROAD OPP 215201505924 ✔ Saving 411229037 ICIC0002
SHARAYU TOYOTA SHOWROOM
PUNE MAHARASHTRA INDIA 411026
Current 152
• Provide a copy of cancelled cheque leaf/pass book/bank statement specifying name of the client, MICR Code or/and IFSC Code of the Bank.
C. DEPOSITORY ACCOUNT(S) DETAILS, if available
Depository Participant Name Name of Depository Beneficiary Name DP ID Beneficiary ID (BO ID)
Finvasia Securities Ganesh Shivaji
Private Limited
NSDL ✔
CDSL
Gawakhare 12084300
NSDL CDSL
• Provide a copy of either Demat Client Master or a recent holding statement issued by DP bearing name of the client.
D. TRADING PREFERENCES
Please sign in the relevant boxes where you wish to trade. Please strike off the segment not chosen by you.
If you do not wish to trade in any of segments/Mutual Fund, Please mention here eSigned using Aadhaar
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST
2023
(4)
G. GST DETAILS (As applicable, State wise)
Legal Name
Trade Name
Tel.: Fax
E-mail
Client Code
Details of disputes / dues pending
from/to such Member / AP:
I. INTRODUCER DETAILS
J. ADDITIONAL DETAILS
(5)
DECLARATION
1. I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we undertake to
inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or
misrepresenting, I am / We are aware that I/we may be held liable for it.
2. I/We confirm having read/been explained and understood the contents of the tariff sheet and all voluntary/non-mandatory documents.
3. I/We further confirm having read and understood the contents of the ‘Rights and Obligations’ document(s), ‘Risk Disclosure Document’ and
‘Do’s and Dont’s’. I/We do hereby agree to be bound by such provisions as outlined in these documents. I/We have also been informed that
the standard set of documents has been displayed for Information on www.finvasia.com.
eSigned using Aadhaar
(Leegality.com - QYIq3p6)
Place PUNE CITY GANESH GAWAKHARE
2 Date: Sat Dec 02 13:08:13 IST
2023
Date 01-12-2023 Client Signature
FOR OFFICE USE ONLY
FA179994
UCC Code allotted to the Client :______________________________
Employee Code
Date
Signature
I / We undertake that we have made the client aware of tariff sheet and all the voluntary/non-mandatory documents. I/We have also made the client
aware of ‘Rights and Obligations’ document (s), RDD, ‘Do’s and Dont’s’ and Guidance Note. I/We have given/sent him a copy of all the KYC
documents. I/We undertake that any change in the tariff sheet and all the voluntary/non-mandatory documents would be duly intimated to the
clients. I/We also undertake that any change in the ‘Rights and Obligations’ and RDD would be made available on my/our website, if any, for the
information of the clients.
For Finvasia Securities Pvt. Ltd.
01-12-2023
Date __________________ Signature of the Authorised Signatory
Seal / Stamp of the Member
(6)
TARIFF CHARGES
2. Charges mentioned above are in respect of services mentioned above only and charges for any service provided to client other than
those listed above shall be charged extra.
3. Late payment penalty @2% p.m. calculated on daily overdue. balance shall be charges till actual realisation.
4. I/we hereby authorize you to Debit charges in respect of pledge of securities against margin/settlement obligations to exchanges,
clearing member, clearing corporation, Banks or any other financial institutions from my Trading Account.
5. There shall be no software charges, However in case of any change in future, clients will be informed with two months notice.
3
Date: Sat Dec 02 13:08:13 IST
2023
(Client Signature)
(7)
ELECTRONIC CONTRACT NOTE (ECN) DECLARATION
To,
Finvasia Securities Pvt. Ltd.
FINVASIA CENTRE, D 179, Phase 8 B (Sector 74)
Mohali, Punjab 160055 (India)
Dear Sir,
I __________________________________
GANESH GAWAKHARE a client with member M/S. __________________________________________
FINVASIA SECURITIES PVT LTD
of_________________________________________________
MCX,NCDEX Exchange undertakes as follows:
• I am aware that the member has to provide physical contract note in respect of all the trades placed by me unless I myself
want the same in the electronic form.
• I am aware that the member has to provide electronic contract note for my convenience on my request only.
• Though the member is required to deliver physical contract note, I find that it is inconvenient for me to receive physical
contract notes. Therefore , I am voluntarily requesting for delivery of electronic contract note pertaining to all the trades
carried out/ ordered by me.
• I have access to a computer and am a regular internet user, having sufficient knowledge of handling the email operation.
• My email id is* _____________________________________________________________________________.
[email protected] This
has been created by me and not by someone else.
• I am aware that this declaration form should be in English or in any other Indian language known to me.
• I am aware that non-receipt of bounced mail notification by the member shall amount to delivery of the contract note at the
above e-mail ID.
• I/We am/are aware that this authorisation can be revoked any time by giving a notice in writing.
The above declaration and the guidelines on ECN given in the Annexure have been read and understood by me. I
am aware of the risk involved in dispensing with the physical contract note, and do hereby take full responsibility
for the same.
*(The email id must be written in own handwriting of the client)
GANESH GAWAKHARE
Client Name: _______________________________________________
FA179994
Unique Client Code : _________________________________________
PAN: _____________________________________________________
ANVPG3853B
111/A/15
Address : __________________________________________________
eSigned using Aadhaar
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
4
Signature of Client
Date: Sat Dec 02 13:08:13 IST
2023
Date :__________________Place:________________________
01-12-2023 PUNE CITY
Signature_________________________________________
(8)
RUNNING ACCOUNT AUTHORISATION
I/We are dealing through you as a client in Capital Market and/or Future & Option segment
and/or Currency segment and/or Commodity segment and/or Interest Rate future Segment and/or
Mutual Fund Segment & in order to facilitate ease of operations and upfront requirement of
margin for trade. I/We authorize you as under:
1. I/We request you to maintain running balance in my account & retain the credit balance in any
of my/our account and to use the unused funds towards my/our margin/pay-in/other future
obligation(s) at any segment(s) of any or all the Exchange(s)/Clearing corporation unless I/we
instruct you otherwise.
2. I/We request you to settle my fund once in 30 days or once in ✔ 90 days or such other
higher period as allowed by SEBI/Stock Exchange time to time except the funds given towards
collaterals/margin in form of Bank Guarantee and/or Fixed Deposit Receipt.
3. In case I/We have an outstanding obligation on the settlement date, you may retain the
requisite securities/funds/Mutual Fund Units towards such obligations and may also retain the
funds expected to be required to meet future margin obligations, calculated in the manner
specified by the exchanges.
4. I/We confirm you that I will bring to your notice any dispute arising from the statement of
account or settlement so made in writing within 30 working days from the date of receipt of
funds/securities or statement of account or statement related to it, as the case may be at your
registered office. The running account authorization provided by me shall continue and remain
valid until it is revoked by me anytime in writing.
Thanking You
Yours faithfully,
(9)
FATCA-CRS Declaration
Please seek appropriate advice from your professional tax professional on your tax residency and related
FATCA & CRS guidance
Place of Birth NA
Country of Birth I ND I A
Nationality I n d i a n
Constitute ✔ Individual HUF NRI Foreign National
Are you a tax resident of any country other than India - Yes ✔ No
If Yes, please indicate all countries in which you are resident for tax purposes and the associated Tax ID Numbers below.
1.
2.
3.
# To also include USA, where the individual is a citizen / green card holder of the USA
% In case Tax Identification Number is not available, kindly provide its functional equivalent $
CERTIFICATION
I / We have understood the information requirements of this Form (read along with the FATCA & CRS Instructions) and
hereby confirm that the information provided by me/us on this Form is true, correct and complete. I / We also confirm
that I / We have read and understood the FATCA & CRS Terms and Conditions below and hereby accept the same.
6
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST
Place : PUNE CITY 2023
Signature
(10)
ACKNOWLEDGEMENT RECEIPT
To,
Finvasia Securities Pvt. Ltd.
FINVASIA CENTRE, D 179, Phase 8 B (Sector 74)
Mohali, Punjab 160055
2. Rights and Obligations of Members, Authorized Persons and Clients (including additional rights & obligations in case of
internet / wireless technology based trading).
3. Guidance Note - Do's and Don'ts for dealing in Commodities Market for Investors.
Yours faithfully,
Client Signature
Client Name
GANESH GAWAKHARE
(11)
NOMINATION FORM (Annexure-A)
(To be filled in by individual applying singly or jointly)
Finvasia Securities Pvt. Ltd.
FINVASIA CENTRE, D 179, Phase 8 B, (Sector 74)
Mohali, Punjab-160055 (India)
DATE D D M M Y Y Y Y UCC
DP ID 1 2 0 8 4 3 0 0 Client ID
I/We wish to make a nomination. [As per details given below]
NOMINATION DETAILS
I/We wish to make a nomination and do hereby nominate the following person(s) who shall receive all the assets held in my / our
account in the event of my / our death.
Nomination can be made upto Details of 1st Nominee Details of 2nd Nominee Details of 3rd Nominee
three nominees in the account
1. Name of the nominee(s)
Mr./Ms.) NA
2. Share of each Equally
Nominee [If not equally, % % %
please specify
percentage] Any odd lot after division shall be transferred to the first nominee mentioned in the form.
3. Relationship with the
Applicant (if any)
4. Address of Nominee(s)
City / Place
State / Country NA
PIN Code
5. Mobile/Telephone No.
of Nominee(s)
6. Email ID of nominee(s)
NA
and provide details of same]
Photograph & Signature
PAN AADHAAR
Saving Bank A/c No.
Proof of Identity
Demat Account ID
Sr. Nos. 8-14 should be filled only if nominee(s) is a minor :
8. Date of Birth {in case of
minor nominee(s)}
9. Name of Guardian (Mr./Ms.)
{in case of minor nominee(s)}
10. Address of Guardian(s)
City / Place
State / Country
PIN Code
11. Mobile/Telephone No.
of Guardian
12. Email ID of nominee(s)
eSigned using Aadhaar
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST (12)
2023
13. Relationship of Guardian
with nominee
14. Guardian Identification details -
[Please tick any one of following
and provide details of same]
Photograph & Signature
PAN AADHAAR
Saving Bank A/c No.
Proof of Identity
Demat Account ID
Third Holder
(Mr./Ms.)
*Signature of witness, along with name and address are required, if the account holder affixes thumb impression, instead of signature.
Note:
This nomination shall supersede any prior nomination made by the account holder(s), if any.
The Trading Member / Depository Participant shall provide acknowledgement of the nomination form to the account holder(s).
DATE 0D 1
D 1
M 2
M 2Y 0
Y 2Y 3
Y UCC F A 1 7 9 9 9 4
DP ID 1 2 0 8 4 3 0 0 Client ID 0 1 9 0 5 2 6 2
I / We hereby confirm that I / We do not wish to appoint any nominee(s) in my / our trading / demat account and understand the issues
involved in non-appointment of nominee(s) and further are aware that in case of death of all the account holder(s), my / our legal heirs would
need to submit all the requisite documents / information for claiming of assets held in my / our trading / demat account, which may also
include documents issued by Court or other such competent authority, based on the value of assets held in the trading / demat account.
Signatures
of Holder(s) 4
PART A
Certificate under Section 203 of the Income-tax Act, 1961 for tax deducted at source on salary paid to an employee under section 192 or pension/interest income
of specified senior citizen under section 194P
Name and address of the Employer/Specified Bank Name and address of the Employee/Specified senior citizen
From To
The Commissioner of Income Tax (TDS)
Room No. 900A, 9th Floor, K.G. Mittal Ayurvedic Hospital 2023-24 01-Apr-2022 31-Mar-2023
Building, Charni Road , Mumbai - 400002
Summary of amount paid/credited and tax deducted at source thereon in respect of the employee
Total (Rs.)
II. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN
(The deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)
1 0.00 - 07-05-2022 - F
2 0.00 - 07-06-2022 - F
3 1761.00 6360017 07-07-2022 06053 F
eSigned4using Aadhaar 1794.00 6360017 06-08-2022 57152 F
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST
2023 Page 1 of 2
Certificate Number: AMHGQMA TAN of Employer: MUMA47146B PAN of Employee: ANVPG3853B Assessment Year: 2023-24
Verification
I, PRAVIN KUMAR AGARWALA, son / daughter of KAMALA PRASAD AGARWALA working in the capacity of DIRECTOR (designation) do hereby certify that a sum
of Rs. 22665.00 [Rs. Twenty Two Thousand Six Hundred and Sixty Five Only (in words)] has been deducted and a sum of Rs. 22665.00 [Rs. Twenty Two Thousand
Six Hundred and Sixty Five Only] has been deposited to the credit of the Central Government. I further certify that the information given above is true, complete and
correct and is based on the books of account, documents, TDS statements, TDS deposited and other available records.
Place Mumbai
Notes:
1. Part B (Annexure) of the certificate in Form No.16 shall be issued by the employer.
2. If an assessee is employed under one employer during the year, Part 'A' of the certificate in Form No.16 issued for the quarter ending on 31st March of the financial year shall contain the details
of tax deducted and deposited for all the quarters of the financial year.
3. If an assessee is employed under more than one employer during the year, each of the employers shall issue Part A of the certificate in Form No.16 pertaining to the period for which such
assessee was employed with each of the employers. Part B (Annexure) of the certificate in Form No. 16 may be issued by each of the employers or the last employer at the option of the assessee.
4. To update PAN details in Income Tax Department database, apply for 'PAN change request' through NSDL or UTITSL.
Name and address of the Employer/Specified Bank Name and address of the Employee/Specified senior citizen
PAN of the Deductor TAN of the Deductor PAN of the Employee/Specified senior citizen
From To
The Commissioner of Income Tax (TDS)
Room No. 900A, 9th Floor, K.G. Mittal Ayurvedic Hospital 2023-24 01-Apr-2022 31-Mar-2023
Building, Charni Road , Mumbai - 400002
Annexure - I
Details of Salary Paid and any other income and tax deducted
Value of perquisites under section 17(2) (as per Form No. 12BA,
(b) 0.00
wherever applicable)
Profits in lieu of salary under section 17(3) (as per Form No.
(c) 0.00
12BA, wherever applicable)
(d) Total NEERU ARYA543179.00
(e) Reported total amount of salary received from other employer(s) E99 0.00
01-12-2023
(a) Travel concession or assistance under section 10(5) 0.00
Page 1 of 3
eSigned using Aadhaar
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST
2023
Certificate Number: AMHGQMA TAN of Employer: MUMA47146B PAN of Employee: ANVPG3853B Assessment Year: 2023-24
7. Add: Any other income reported by the employee under as per section 192 (2B)
(b) Income under the head Other Sources offered for TDS 0.00
(d) Total deduction under section 80C, 80CCC and 80CCD(1) 0.00 0.00
Page 2 of 3
eSigned using Aadhaar
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST
2023
Certificate Number: AMHGQMA TAN of Employer: MUMA47146B PAN of Employee: ANVPG3853B Assessment Year: 2023-24
Verification
I, PRAVIN KUMAR AGARWALA, son/daughter of KAMALA PRASAD AGARWALA .Working in the capacity of DIRECTOR
(Designation) do hereby certify that the information given above is true, complete and correct and is based on the books of account,
documents, TDS statements, and other available records.
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eSigned using Aadhaar
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GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST
2023
FORM NO. 16
PART B
Certificate under section 203 of the Income-tax Act, 1961 for tax deducted at source on salary paid to an employee under section 192 or pension/interest income
of specified senior citizen under section 194P
Name and address of the Employer/Specified Bank Name and address of the Employee/Specified senior citizen
PAN of the Deductor TAN of the Deductor PAN of the Employee/Specified senior citizen
From To
The Commissioner of Income Tax (TDS)
Room No. 900A, 9th Floor, K.G. Mittal Ayurvedic Hospital 2023-24 01-Apr-2022 31-Mar-2023
Building, Charni Road , Mumbai - 400002
Annexure - I
Details of Salary Paid and any other income and tax deducted
Value of perquisites under section 17(2) (as per Form No. 12BA,
(b) 0.00
wherever applicable)
Profits in lieu of salary under section 17(3) (as per Form No.
(c) 0.00
12BA, wherever applicable)
(d) Total NEERU ARYA543179.00
(e) Reported total amount of salary received from other employer(s) E99 0.00
01-12-2023
(a) Travel concession or assistance under section 10(5) 0.00
Page 1 of 3
eSigned using Aadhaar
(Leegality.com - QYIq3p6)
GANESH GAWAKHARE
Date: Sat Dec 02 13:08:13 IST
2023