Information to be provided under sub-section (5) of section 90 or sub-section (5) of section 90A of the Income-tax Act, 1961
I ………………. *son/daughter of Shri ………………. in the capacity of ………………. (designation) do provide the following information, relevant to the previous year ………………. *in my case/in the case of ………………. for the purposes of sub-section (5) of *section 90/section 90A:-
Sl.No. Nature of information Details
(i) Status (individual; company, firm etc.) of the assessee
(ii) Permanent Account Number (PAN) of the assessee if allotted
(iii) Nationality (in the case of an individual) or Country or specified territory of incorporation or registration (in the case of others)
(iv) Assessee’s tax identification number in the country or specified territory of residence and if there is no such number, then, a unique number on the basis of which the person is identified by the Government of the country or the specified territory of which the assessee claims to be a resident
(v) Period for which the residential status as mentioned in the certificate referred to in sub-section (4) of section 90 or sub-section (4) of section 90A is applicable
(vi) Address of the assessee in the country or territory outside India during the period for which the certificate, mentioned in (v) above, is applicable
2. I have obtained a certificate to in sub-section (4) of section 90 of sub-section (4) of section 90A from the Government of ………………. (name of country or specified territory outside India)
Signature:……………….
Name:……………….
Address:……………….
Permanent Account Number:……………….
Verification:
I ………………. do hereby declare that to the best of my knowledge and belief what is stated above is correct complete and is truly stated.
Verified today the ………………. day of ………………..
……………….
Signature of the person providing the information
Place:……………….
Notes :
1. *Delete whichever is not applicable.
2. #Write N.A. if the relevant information forms part of the certificate referred to in sub-section (4) of section 90 or sub-section (4) of section 90A.