FORM        INTIMATION TO THE ASSESSING OFFICER OF                                                        For Office use only
                         34BA          HAVING MADE AN APPLICATION TO THE                                                    Receipt No.             Date
                                               SETTLEMENT COMMISSION                                                        ....................... ...............
                                      (See Section 245C of the Income-tax Act, 1961
                                        and rule 44C of the Income-tax Rules, 1962)                                         Seal and Signature of





                                                                                                                            Receiving Official


                           Name                                                                                                                 PAN
  PERSONAL INFORMATION




                           Flat/Door/Block No.                 Name of Premises/                                         Status                            (Tick) ;
                                                               Building/Village
                                                                                                                  (i)    Individual
         PART-A




                                                                                                                 (ii)    Hindu undivided family
                           Road/Street/Post    Office          Area/Locality                                   (iii)     Company
                                                                                                                (iv )    Firm
                           Town/City/District                  State             Pin Code                        (v)     Cooperative Society
                                                                                                                (vi )    Local Authority
                                                                                                               ( vii )   Association of persons/
                           E-mail Address                      STD code and Phone                                        Body of individuals not
                                                               Number (      )                                           covered by (v) or (vi)


                                1.   Designation of Assessing Officer (Ward/Circle)
JURISDICTION AND
  FILING STATUS
   ASSESSMENT
      PART-B




                                2.   The Commissioner having jurisdiction over the applicant


                                3.   Assessment year(s) in connection with which the application for settlement is made and
                                     the date of filing the return








                                                                          CERTIFICATE

 I, ....................................................................................., son/daughter/wife of .......................................................
 do hereby certify that I have made today an application in Form No. 34B under sub-section (1)
 of section 245C of the Income-tax Act with above-mentioned particulars to the Settlement
 Commission at .................. Bench by post/by hand (delete whichever is not applicable ) vide
 Receipt No. .......................... (write receipt No. in the case application has been made by hand) in
 my capacity as ........................ [write your designation]


 Place                                   Date                                                  Signature of applicant