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Form & Application for remittance under section 195
of the Income-tax Act

1.

Name and Address of the Applicant and principal place of business

:

2.

Name and Address of the Assessing Officer having jurisdiction over theremitters

:

3.

Applicants PAN Number

:

4.

Name and address of the beneficiary of the remittance and the country towhich remittance is made

:

5.

Amount and nature of remittance

:

6.

Rate of deduction of tax at source

:

7.

Reference to provision of Act/DTAA under which the rate has been determined

:

8.

Certificate

 

(i)I/We propose to make the above remittance as per deduction of tax at source indicated above. We have obtained a certificate from M/s. ..... who is an accountant as defined in section 288 of the Income-tax Act, certifying the amount, nature and correctness of deduction of tax at source.

(ii)In case the income-tax authority at any time finds that tax actually deductible on the amount of remittance has either not been paid or not paid in full, I/we undertake to pay the said amount of tax along with interest due.

(iii)I/We shall also be subjected to the provisions of penalty for the said default as per the provisions of Income-tax Act.

(iv)I/We undertake to submit the requisite documents, etc., for enabling the income-tax authorities to determine the nature and amount of income of the beneficiary of the above remittance as well as documents required for determining our liabilities under the Income-tax Act as a person responsible for deduction of tax at source.

(v)The information given above is true to the best of my/our knowledge and belief and no relevant information has been concealed.

..............................................

Name and Signature

[To be signed by a person responsible for signing the return of income (as to provisions of section 139(A) of the Income-tax Act) of the person making the remittance].

Annexure B

Certificate

I/We have examined the agreement (wherever applicable) between M/s. ............................ ..................................................................... and M/s. ........................................................ requiring the

remittersbeneficiary

above remittance as well as the relevant documents and books of account required for ascertaining the nature of remittance and for determining the rate of deduction of tax at source as per provisions of section 195. We hereby certify the following :

1.

Name and address of the beneficiary of the remittance and the name of the foreign country to which remittance is being made.

:

 

 

2.

Amount of remittance is foreign currency indicating the proposed date/month and bank through which remittance is being made.

:

 

 

3.

Details of tax deducted at source, rate at which tax has been deducted and date of deduction.

:

Foreign Currency

Indian Currency

 

Amount to be remitted

 

.....

.....

 

Tax deducted at source

 

.....

......

 

Actual Amount remitted

 

.....

.....

 

Rate at which deducted

 

.....

.....

 

Date of Deduction

 

......

.....

4.

In case the remittance as indicated in (2) above is net of taxes, whether tax payable has been grossed up? If so, computation thereof may be indicated.

:

 

 

5.

If the remittance is for royalties, fee for technical services, interest, dividend, etc., the clause of the relevant DTAA under which the remittance is covered along with reasons and the rate at which tax is required to be deducted in terms of such clause of the applicable DTAA.

:

 

 

6.

In case that tax has been deducted at a rate lower than the rate prescribed under the applicable DTAA, the reasons thereof.

:

 

 

7.

In case remittance is for supply of articles or things (e.g., plant, machinery, equipment, etc.) or computer software, please indicate :

:

 

 

 

i. Whether there is any permanent establishment in India through which the beneficiary of the remittance is directly or indirectly carrying on such activity of supply of articles or things?

 

 

 

 

ii. Whether such remittance is attributable to or connected with such permanent establishment?

 

 

 

 

iii .If so, the amount of income comprised in such remittance which is liable to tax.

 

 

 

 

iv. If not, the reasons in brief therefor.

 

 

 

8.

In case remittance is on account of business income

 

 

 

 

please indicate :

:

 

 

 

i. Whether such income is liable to tax in India?

 

 

 

 

ii. If so, the basis for arriving at the rate of deduction of tax.

 

 

 

 

iii. If not, the reasons thereof.

 

 

 

9.

In case tax is not deducted at source for any other reason,details thereof.

:

 

 

(Attach separate sheet duly authenticated wherever necessary)

.........................................................................................

Name, Address and registration numbers

(To be signed and verified by an Accountant as defined in section 288 of the Income-tax Act).

[ The aforesaid form is annexure to the Circular : No. 10/2002, dated 9-10-2002.

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