FORM NO.63
[See rule 12B]
Statement to be furnished to the Assessing Officer designated under rule 12B of the Income-tax
Rule, 1962, in respect of income distributed by the Unit Trust of India
(Separate forms to be filled up for each scheme)
1. Address of Registered Office
2. Permanent Account Number
3. Previous Year ending
4. Name and address of the office bearers
5. Name of Scheme
6. Face Value of Unit
7. Total No. of Units
8. Details of income distributed
Distribution or Tax payable Interest Payment towards
Payment of Income under section chargeable tax and interest
115R under under section 115-S
section 115S, (Attach a copy
if any of challans)
Date(s) Amount(s)
Dates(s) Amount(s)
9. Tax payable on income
distributed to the Unitholders.
Enclose audit account including balance sheet, annual report, if any, with certified copies of
income and appropriation towards distribution of income.
I …………………………………………………… son/daughter/wife of ………………………………… do hereby
(name in full and in block letters)
solemnly declare that to the best of my knowledge and belief what is stated above and in the
annexure(s), including the documents accompanying such annexure(s), is correct and complete. I
further declare that I am furnishing such statement in my capacity as …………………………….. and that
(designation)
I am competent to furnish this statement and verify it.
Verified today the ……………………..day of …………………..
Place ………………………….
Signature ……………………………….
Verification
I/We …………………………………………………………………………….. have examined the books of
accounts and other documents showing the particulars of income earned and the income distributed
to the unitholders by the Unit Trust of India for the previous year ending ……………………..
2. I/We declare that the above particulars are true and correct to the best of my/our knowledge
and belief.
Place …………………………
(Signature with name of the accountant)
Date …………………………
Notes.-1. Accountant” means the accountant as defined in the Explanation to sub-section (2) of
section 288 of the Income tax Act, 1961.