| VIJAYA BANK |
| Branch : |
| Form No.60 / See third proviso to rule
114B |
| [Form of declaration to be filed by a person,
who does not have either a Permanent Account Number or General Index
Register Number and who makes payment in cash in respect of
transaction specified in clause (a) to (h) of rule
114B] |
| |
| Sl.
No |
Particulars |
Information |
| 1. |
Full name &
address of the declarant |
|
| 2. |
Particulars of
transaction |
|
| 3. |
Amount of
transaction |
|
| 4. |
Are you assessed to
tax |
|
| If yes, Details of
Ward / Circle / Range, where the last return of income was
filed |
|
| Reason for not
having Permanent Account Number / General Index Register
Number |
|
| 5. |
Details of the
document being produced in support of address in column
(1) |
| |
| |
| Verification |
| |
I,
________________________ , do hereby declare that what is stated
above is true to the best of my knowledge and
belief.
Verified today, the _______________ day of
____________ ,
SIGNATURE OF
DECLARANT
Place:
Date: |
| |
| Instructions |
| Documents, which can be produced in support of the address
are: |
| 1. |
Ration Card. |
| 2. |
Passport |
| 3. |
Driving
Licence. |
| 4. |
Identity
Card issued by any institution. |
| 5. |
Copy of
the Electricity Bill or Telephone Bill showing residential
address. |
| 6. |
Any
document or communication issued by any authority of Central
Government, State Government or Local Bodies showing
residential address. |
| 7. |
Any other
documentary evidence in support of his address in the
declaration. | |
| |