FORM NO.               APPLICATION FOR SETTLEMENT OF CASES                                In the Settlement
                                 34B                 (See section 245C of the Income-tax Act, 1961                         Commission
                                                       and rules 44C and 44CA of the Income-tax                        At ................... Bench
                                                                     Rules, 1962)                                    Settlement Application
                                                                                                                      No. .........20.....20.........


                                          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


                                             1.   The date from which the proceedings are pending. (Assessment year wise)
 PAYMENT OF ADDITIONAL TAX AND INTEREST
  PARTICULARS OF INCOME DISCLOSED AND




                                             2.   Particulars of the issues to be settled, nature and circumstances of the case. (Assessment
                                                  year wise)


                                             3.   Full and true disclosure of income which has not been disclosed before the Assessing
                                                  Officer. (Assessment year wise)
                 PART-C




                                             4.   The additional amount of income-tax payable on income referred to in (3). (Assessment
                                                  year wise)


                                             5.   Interest payable. (Assessment year wise)


                                             6.   Total of (5) and (6)

                                             7.   Date of payment of tax and interest referred to in (7)
                                                                     VERIFICATION

I, .................., son/daughter/wife of ............................do hereby solemnly declare that to the best of
my knowledge and belief, what is stated above and in the Annexure [including the statement(s)
and documents accompanying such Annexure] is correct and complete. I further declare that
I am making this application in my capacity as ................................................... [write your designa-
tion] and that I am competent to make this application and to verify it. I also certify that the
proceedings for which this application is being made is not covered by the proviso to clause (b)
of section 245A of the Income-tax Act.
Verified today the ...................................................day of ........................................................


        Place                                    Signature of applicant

                                                                        ANNEXURE
                    Statement containing particulars referred to in Part-C, item 3 of the
                       application under section 245C(1) of the Income-tax Act, 1961

1.      Amount of income which has not been disclosed before the Assessing Officer (same as
        in Part-C, item 3 of the application)


2.      Additional amount of income-tax payable on the said income


3.      Interest payable


4.      Full and true statement of facts regarding the issues to be settled, including the terms
        of settlement sought for by the applicant. (Assessment year wise)




5.      The manner in which the income referred to item No. 1 has been derived. (Assessment
        year wise)




     Place                                Date                                 Signature of Applicant