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Ming certain receipts without deduction of tax. PART - I 1 Name of Assessee (Declareant) : ( ) 2 PAN : 3 Age : 4 Assessment Year : 5 Flat / Door / Block No. : 6 Name of Premises : 8 Road / Street / Lane : 9 Area / Locality : 11 Town / City / District : 12 State : 15 Email : 13 PIN 16 Telephone / Mobile No : 7 Assessed in which Ward / Circle : 10 AO Code (whom assessed last time) : Area Code AO Type Range Code AO No No. 14 Last Assessment Year in which assessed.

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