I FORM 60 i erat een EET Form or delraon oe le by anni or a parson (ot eng a compar orf) who does nathave permanent acourt ruber an who ene into ary rensacon speifedin ue 1148 {account Number : | custio: i First Name Middle Name/ Surname (Please leave one space between words) 2 Fitst Name (incase of individu Middle Name/ Surname (Please leave one space between words) Date of Birth’ Incorporation of Declarant 4. Flat/ Room No & Name of Premises 5._Block or Road Name/No, 6. Area 7. Town/City 8. District 8. State 10. PIN 11-Telephone No. (with STD code) 12. Mobile No 13. Amount of transaction | (Rs.) Ps) 14, In case of transaction in joint names, number 15, Date of transaction ‘of persons involved in the transaction 16. Mode of transaction: (Please tick the relevant box) _|]Cash (“| Cheque |] Card[_ DraftBanker's Cheque _JOnlne transfer (ther 417. Aadhaar Number issued by UIDAI (it available) 18. If applied for PAN and tis not yet generated enter date of application and acknowledgement number 19. I PAN not applied, fil estimated total income (including income of spouse, minor chid etc. as per section 64 of Income-tax Act, 1961) for the financial year in which the above transaction is held 2) Agricultural income (Rs.) b) Other than agricultural income(Rs.) 20.Detas of document being | Document code [Document identification ‘Namo and address of the authority issuing the document Produced in support of identity number (Refer instruction overeat) 21 Detas of document being | Document code [Document identification ‘Name and address af the authority issuing the document produced in support of number address (Refer Instruction overie Verification 1 ‘do hereby declare that what is stated above is true to the best of my knowledge and belief. further declare that I do not have a Permanent Account Number and my/ our estimated total income (including income of spouse, minor child etc. as per section 64 of Income-tax Act, 1961) computed in accordance with the provisions of Income-tax Act, 1961 for the financial year in which the above transaction is held willbe less than maximum amaunt nat chargeable to tax. Verified today, the ay of 20. Place: (Signature of decarant) Note: 1. Before signing the declaration, the dectarant should satisty himself thatthe information furnished in tis form is true, correct and complete in all respects. Any person making a fase statement in the declaration shall be lable to prosecution under section 277 ofthe Income-tax Act, 1961 and on conviction be punishable:- (iin case where tax sought to be evaded exceeds twenty-five lakh rupees, with rigorous imprisonment which shall not be less than six months but Which may extend to seven years and with fine; (iin any other case, with rigorous imprisonment which shall not be les than three months but which may extend to two years and with fine, 2. The person accepting the declaration shall not accept the declaration where the amount of income ofthe nature referred to in item 19b exceeds the ‘maximum amount which is not chargeable to tax, unless PAN is applied for and column 18 is duly file. eae aa [State code. ‘Name of Employee County code Employee Code. on rigs Fa bsgneseatone! TT oe sting Version No.4 3