Part II
(For use by the person to whom the declaration is furnished)
1. Name of the person responsible for paying the income referred to in column 22 of part I
2. PAN of the person indicated in column 1 of Part II
3. Complete Address
4. TAN of the person indicated in column 1 of Part II
5. Email
6. Telephone No. with STD Code and mobile no.
7. Status
8. Date on which declaration is furnished (dd/mm/yy)
9. Period in respect of which the dividend has been declared or the income has been paid/credited
10. Amount of income paid
11. Date on which the income has been paid/credited (dd/mm/yy)
12. Date of declaration, distribution or payment of dividend/withdrawal under the NSS (dd/mm/yy)
13. Account Number of Nss from which withdrawal has been made
Forwarded to the chief commissioner or commissioner of income tax ……………………………………………………..
Place :
Date:
Signature of the person responsible for
paying the income referred to in column 22 of Part I