$+R, N+" -.

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01ee section -23A(-)4 -23A(-A) and ru(e 52C6 Dec(aration under section -23A(-) and section -23A(-A) of the Incometa% Act4 -27- to &e made &y an individua( or a person (not &eing a company or firm) c(aiming certain receipts without deduction of ta%"

PAR* I

-" Name of Assessee (Dec(arant)

5" PAN of the Assessee 8" Assessment 9ear ( for ;which dec(aration is &eing made) 7" 1tatus 3" Assessed in which <ard/Circ(e

:" $(at/Door/B(oc No"

." Name of Premises

=" Road/1treet/!ane

2" Area/!oca(ity

->" A+ Code(under whom assessed (ast time)

--" *own/City/District

-5" 1tate -8" PIN

-." ?mai( -2" Name of Business/+ccupation

-7" *e(ephone No" (with 1*D Code) and ,o&i(e No"

(if not same as a&ove)

Present A+ Code

5-" @urisdictiona( Chief Commissioner of Incometa% or Commissioner of Income ta% (if not assessed to Incometa% ear(ier) 55" ?stimated tota( income from the sources mentioned &e(ow#

Area Code A+ *ype Range Code

A+ No"

(P(ease tic the re(evant &o%) Dividend from shares referred to in 1chedu(e I Interest on securities referred to in 1chedu(e II Interest on sums referred to in 1chedu(e III Income form units referred to in 1chedu(e IA *he amount of withdrawa( referred to in section =>CCA(5)(a) from Nationa( 1avings 1cheme referred to in 1chedu(e A 58" ?stimated tota( income of the previous year in which income mentioned in Co(umn 55 is to &e inc(uded 5:" Detai(s of investments in respect of which the dec(aration is &eing made# 1CB?DC!?I (Detai(s of shares4 which stand in the name of the dec(arant and &eneficia((y owned &y him) No" of shares NA C(ass of shares ) face va(ue of each share NA *ota( va(ue of shares NA Distinctive num&ers of the shares NA 1CB?DC!?II Date(s) on which the shares were ac'uired &y the dec(arant(dd/mm/yyyy) NA

(Detai(s of the securities he(d in the name of dec(arant and &eneficia((y owned &y him)
Description of securities Num&er of securities Amount of securities Date(s) of securities (dd/mm/yyyy) Date(s) on which the securities were ac'uired &y the dec(arant(dd/mm/yyyy)

(Detai(s of the sums given &y the dec(arant on interest) Name and address of the person to whom the sums are given on interest Amount of sums given on interest Date on which the sums were given on interest ( dd/mm/yyyy ) Period for which sums were given on interest Rate of interest

1CB?DC!?III

ICICI Ban !td" Customer ID # $i%ed Deposit num&ers#

Name and address of the mutua( fund NA

1CB?DC!?IA (Detai(s of the mutua( fund units he(d in the name of dec(arant and &eneficia((y owned &y him) C(ass of units and face va(ue of each Num&er of Distinctive num&er of units unit units NA NA NA

Income in respect of units NA

1CB?DC!? A (Detai(s of the withdrawa( made from Nationa( 1avings 1cheme) Particu(ars of the Post +ffice where the account under the Nationa( 1avings 1cheme is maintained and the account num&er NA Date on which the account was opened(dd/mm/yyyy) NA

*he amount of withdrawa( from the account NA

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

DD1ignature of the Dec(arant Dec(aration / Aerification DI/<eEE"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""EEEEEEEEEEdo here&y dec(are that to the &est of Dmy/our now(edge and &e(ief what is stated a&ove is correct4 comp(ete and is tru(y stated" DI/<e dec(are that the incomes referred to in this form are not inc(udi&(e in the tota( income of any other person u/s 7> to 7: of the Incometa% Act4 -27-" DI/<e further4 dec(are that the ta% Don my/our estimated tota( income4 inc(uding Dincome/incomes referred to in Co(umn 55 a&ove4 computed in accordance with the provisions of the Incometa% Act4 -27-4 for the previous year ending on E"""""""""""""""""""""""""""""""""""""" re(evant to the assessment year E""""""""""""""""""""""""""" wi(( &e ni(" DI/<e a(so4 dec(are that Dmy/our Dincome/incomes referred to in Co(umn 55 for the previous year ending on E""""""""""""""""""""""""""""""""" re(evant to the assessment year E"""""""""""""""""""""""""""""""" wi(( not e%ceed the ma%imum amount which is not chargea&(e to incometa%"
P(ace# Date#
EEEEEEEEEEEEE"""" EEEEE""""""""""""""""""""""""""""""""" EEEEEEEEE""""""""EEEEEE

1ignature of the Dec(arant

PAR* II
0$or use &y the person to whom the dec(aration is furnished6

-" Name of the person responsi&(e for paying the income referred to in Co(umn 55 of Part I
8" Comp(ete Address

5" PAN of the person indicated in Co(umn - of Part II

ICICI Ban !imited

AAACI--2.B
:" *AN of the person indicated in Co(umn - of Part II

." ?mai(

7" *e(ephone No" (with 1*D Code) and ,o&i(e 3" 1tatus No" 2" Period in respect of which the ividend has &een dec(ared or the income has &een paid/credited ->" Amount of income paid --" Date on which the income has &een paid/ credited(dd/mm/yyyy)

=" Date on which Dec(aration is $urnished (dd/mm/yyyy)

-5" Date of dec(aration4 distri&ution or payment of dividend/withdrawa( under the Nationa( 1avings 1cheme(dd/mm/yyyy)

-8" Account Num&er of Nationa( 1aving 1cheme from which withdrawa( has &een made

$orwarded to the Chief Commissioner or Commissioner of Incometa%EEEEEEEEEEEEEEEEEEEEEE

P(ace# Date#

EEEEEEEEEEEE""""""" EEEEEEEEEEEEEEEE"""""""""""""""""""" EEEEE""""""""""""""""""""""""""""""""

1ignature of the person responsi&(e for paying the income referred to in Co(umn 55 of Part I

Notes# -" *he dec(aration shou(d &e furnished in dup(icate" DDe(ete whichever is not app(ica&(e" 5" 8" ; Dec(aration can &e furnished &y an individua( under section -23A(-) and a person (other than a company or a firm) under section -23A(-A)" :" DDIndicate the capacity in which the dec(aration is furnished on &eha(f of a BC$4 A+P 4 etc" ." Before signing the dec(aration/verification 4 the dec(arant shou(d satisfy himse(f that the information furnished in this form is true4 correct and comp(ete in a(( respects" Any person ma ing a fa(se statement in the dec(aration sha(( &e (ia&(e to prosecution under 533 of the Incometa% Act4 -27- and on conviction &e punisha&(e i) In a case where ta% sought to &e evaded e%ceeds twentyfive (a h rupees4 with rigorous imprisonment which sha(( not &e (ess than 7 months &ut which may e%tend to seven years and with fineF ii) In any other case4 with rigorous imprisonment which sha(( not &e (ess than 8 months &ut which may e%tend to two years and with fine" *he person responsi&(e for paying the income referred to in co(umn 55 of Part I sha(( not accept the dec(aration where the amount of income of the nature referred to in su&section (-) or su&section (-A) of section -23A or the aggregate of the amounts of such income credited or paid or (i e(y to &e credited or paid during the previous year in which such income is to &e inc(uded e%ceeds the ma%imum amount which is not chargea&(e to ta%"GF

7"