FORM NO. 13

[See rule 28(1)]

Application by a person for a certificate under section 197 of the

Income-tax Act, 1961, for no deduction of tax or deduction of

tax at a lower rate

To

The Assessing Officer,

……………………….

……………………….

……………………….

I, ………………………………..…………………………of …………………………………. do hereby, request that a

certificate may be issued to the person responsible for paying to me the income by way of salary/ interest on

securities/interest other than “interest on securities”/insurance commission/dividends /rent /income in    respect

of  units (strike out whichever is not applicable) authorising him not to deduct income-tax/to deduct

income-tax at the rate of …………………………. per cent at the time of payment to me of such income. The

particulars of my income are as under:

(i) Status (state whether individual, HUF, firm, BOI, etc.)

(ii) Residential status (whether resident/resident but not ordinarily resi-

dent/non-resident)

(iii) Permanent Account Number, if any

(iv) Assessment year to which the payments relate

(v) Estimated total income of the previous year relevant to the assess-

ment year referred to in (iv) above

(v) Total tax payable on the income at (v)

(vii) Average rate of tax

Col.(vi)

 x 100

Col.(v)

(viii) How the liability determined in col.  (vi)  is proposed to be  dis-

charged ?(Specify the amount to be paid by way of advance tax

and TDS)

(ii) Total income assessed in the last three assessment years and the

total tax paid for each such year:

 Total

 Total

income

 tax

(i)

(ii)

(iii)

(x) Date and amount of advance tax and TDS, if any, already paid so

far.

(xi) Details of  income claimed to be exempt and not included in the total income

(please append a note giving reason for claiming such exemption).

(xii) Please furnish the particulars in the Schedules below in respect of the payments for which the

certificate is sought:

SCHEDULE I

Description of Number of Date of Amount of

securities securities securities securities

(1) (2) (3) (4)

SCHEDULE II

Sl. No. Name and Amount of The date on Period for Rate of

address of such sum which such which such interest

the person

 sums were sums were

to whom the

 given on given on

sums are

 interest interest

given on

interest

(1) (2) (3) (4) (5) (6)

SCHEDULE III

Sl. Name and address of person responsible for Amount of insurance

No. paying insurance commission commission

(1)

 (2)

 (3)

SCHEDULE IV

Sl. No. Name and No. of Class of Total face Distinctive

address of shares shares and value of Nos. of

the

 face value of shares shares

company

 each share

(1) (2) (3) (4) (5) (6)

SCHEDULE V

Sl.No. Name and Period of Amount Income Income Total

address of employ- of salary from from income

the ment received house sources

employer

 property other than

salary and

income

from

house

property

(1) (2) (3) (4) (5) (6) (7)

SCHEDULE VI

Sl. Name and address of person responsible Amount of

No.

 for paying rent

 rent

(1)

 (2)

 (3)

SCHEDULE VII

Sl. No. Name and Number. of Class of units Total face Distinctive

address of units and face value of Nos. of

the mutual

 value of each units units

fund

 unit

(1) (2) (3) (4) (5) (6)

*I, ………………………………..……………… the trustee/co-trustee of ………………………………..…… do hereby

declare that the securities/sums/shares, particulars of which are given in the Schedules above, are property

held under trust wholly for charitable or religious purposes and that the income therefrom qualifies for

exemption under sections 11 and 13 of the Income-tax Act, 1961.

*I declare that the securities/sums/shares, particulars of which are given in the Schedules above, stand in

my name and are beneficially owned by me, and the income therefrom is not includible in the total income

of any other person under sections 60 to 64 of the Income-tax Act, 1961.

I further declare that what is stated in this application is correct.

 ………………………….

(Signature)

Date ………………..

 ……………………….

Place ……………….

 ……………………….

……………………….

(Address)

*Strike out whichever is not applicable.