To
MCS Limited, '
(Unit : Sardar Sarovar Narmada Nigam Limited)101, Shatdal Complex, Opp. Bata Show Room, Ashram Road, Ahmedabad - 380 009.Phone : 079 - 2658 2878 - 80 (3 lines), 2658 4027 Fax : 079 - 2658 1296Email : [email protected]
Dear Sir,Sub :- Redemption of SSNNL Deep Discount Bonds.
(1) The following duly discharged Deep Discount Bond Certificate(s) are enclosed herewith for redemption.
Folio No. DDB GertificateNo.
Districtive Nos. Number ofBondsFrom lo
(A separate sheet may be attached if required)
Change of address of Sole/First holder (if any)
Pin Code No.(3)
(2)
City
(4)
(5)
Date:Place
lncome Tax Deduction Status :
(a) Form 15 G in duplicate (Form
:
lI Exempted f, Non exempted15G Enclosed. Kindly fillup the necessary details and send it to us.)
Bank details :
Bank Account Tvpe f] Savinqs n Current
Bank Account NumberName of the BankBank address
CityPIN Code
9 digit MICR Code No.(Enclose copy of the cancelled cheque )
Third HolderSole/First Holder
Enclose photo
copy of PAN Card
Signature of the Sole/First Holder
For the use of Registrars :
Date of Receipt lnward No. Date of entry Remarks
Folio No. have to be written properly in all enclosure to this proforma.
Signature required at the back of the bond and wherever required.Note : 1.'2
FSRtul Fdffi, 15GtSee section 197A(lC), 197A(1A) and rLile 29Cl
Declaration under section 197A(1) and section 197A (iA) of the InconTe-tax Act, 1961 to be made by an individual or Person (not being a conrpany or firm)claiming {ertain receipts without deduction of tax,
PART - X
1l Name bf Assessee (Declareant) : 2] PAN :
3l Assessment Year ?0n 6-17
6l Status :
4l Flal / Door / Block No, 5l Name of Premises : 7l Assessed in
which Ward / Circle
8l Road / Slreet / Lane : 9l Area i Locality :101 A0 Code (whorn assessed last time)
Area Code AO Type Range Code AO l,,lo.
lil Town i City / Distrid : 121 State :
141 Last Assessment Yearin which assessed :
2t)15-16131 PrN
151 Email 161 Telephone I Mobile No : 171 Present Ward'l Circle
181 Residential Status : Reident
191 Narne af Business / Occupation :
201 Present AO Code (if not same as above):
211 Jurisdictional Chief Camm, of Incorne Tax or Comm. ofIncorne Tax {if not assessed to income tax earlier):
Area Code AO Type Range Code AO No.
221 Estimated total income from the sources mentioned below: (Please tick the relevant box)
Dividend from shares referred to in Schedule - iinterest on securities referred to in Schedule - II
Interest on surns referred to in Schedule - III vIncorne from units referred to in Scheduie - IV
The amt of withdrawai referred in sec-B0CCA{2Xa) from National Savings ftheme referred to in Schedule - V
231 Estimated total incorne of the previous year in lncsme mentioned in Col - 22 to be included :
241 Details of investments in respect of which the declaration is being made :
SCHEDULE.T
(Details of shares, which stand in the name of the declarant and beneficially owned 9y ltm)No. of
shares
Class of shares & face
value of each share
lotal value
of shares
Distinctive numbers
of the shares
Date on which the shares were acquired
by the declarant (dd/mm/yyyy)
SC}IEDULE-II
{Details of the securities held in the name of declarant and beneflcially ownqd by !im)Date(s) on which the securitues were
acquired by ceclarant (dd/mmiyyW)
Dateis) of
securi lies 4dd/mm/VWV)
, SCf{fDULffi.IIg
(Details of the sums given by the declarant on intei"est)
Name and address of the person io
whr:n the surns are given 0n interest
Amount of sums
given on inters;t
Date on l',rhich sumsgiven
on interest{dd/mmlww)
Period for which sums
r,vere given on interesf
R.ate of
interest
$ce{Epii{"H- E'[f
iDei*iis *f ihe mutual i;rrd units held !n the nrme cf deciarant and benefieiaily on'ned by hirri)
iun:e *nri ;irldress of tn*
rn*iual iund
Class oi units & faie
value af each u*it
Distinctive i
numher
pf units
SCHEDULE.V
(Details of the withdrawal made from National Savings Scheme)
Particulars of_the Post Office where the account under the
National Savings Scheme is maintained and the account number
Date on which the account
was opened (dd/mm/yyyy)
The amount of withdrawal
frorn the account
Signature of the Declarant
Declaration / Verification
*I/ We do hereby declare that to the best of
knowledge and belief what is stated above is correct, complete and truly stated. *I Affe declare that incomes referred to inthis form are not includible in the total income of any other person u/s 60 to 64 of Income Tax Act, 1961. xIAVe further,
declare that tax *on my I our estimated totai income, including *income / incomes referred to in column 22 above,
computed in accordance with provisions of the Incorrre Tax Act 1961. for the previous year ending on 31.03.2015 relevantto the relevant to the assessment year 2016-17 will be nil,xI I We also, declare that xmy / our xincome / incomes referred to in Column 22 for the previous year ending on
31.03.2016 relevant to the assessment year 2016-17 will not exceed the maximum amount which is not chargeable toincome tax.
Signature of the DeclarantPlace :
Date :
PART - IIFor use bv the to whom the declaration is
il Name of the person
in Column 22 of Part tr
responsible for paying the income referred to 2l PAN of the person indicated in Column 1 of Paft II
3l Complete Address : 4l TAN of the person indicated in
Column 1 of Part II :
5l Email : 6l Telephone / Mobile ltlo : 7l Status :
8l Date on which Declaration is
Furnished (dd/mni/yyyy) :
9l Period in respect of which thedividend has been declared or theincome has been paid / credited :
101 Amount ofincome paid :
111 Date on which the income has
been paid I credited(dd/mm/yyyy) :
121 Date of declaration, distribution or payment ofdividendlwithdrawal under the Nationa! Savings
Scheme{dd/mm/yyyy) :
13.l Aecount Number of National Saving
withdrawal has been made :
Scheme from which
Fcrwarded tc the Chief Commissioner or Cornmissloner of income-tax
Plac* :
Dar,r
II
I
I_l
.$rgnaft,L"e *f the person respanstble far paying the
jnrrr?s referred ta in Cr:lunn ?1 *f Fart I
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