'FORM NO.

27
(See rule 37A)
Statement of deduction of tax from interest, dividends or any other sum payable to (i) persons, not being companies, who are non-residents or residents but not ordinarily
residents, and (ii) companies which are neither Indian companies nor companies which have made the prescribed arrangements for the declaration and payment of dividends
within India, for the period ending________________.
1. Particulars of the person making deduction of tax
(a) Name
(b) Address : Flat / Door/ Block No.
Name of Premises / Building/
Road / Street / Lane
Area / Locality /
Town / District / City PIN
State

(c) Tax Deduction Account Number

(d) Permanent Account Number
2.* Has address of the person making deduction of tax changed Tick as applicable Yes No
3. Status as defined within the meaning of section 204 read with rule 30 Tick as applicable Central Govt. Others
4. (a) Please tick the boxes below indicating the section and type of payment (other than "Salaries") made during the year from which tax was required to be deducted at source by you
under the Income Tax Act, 1961
193 194E 195 196A 196B 196C 196D
(b) Please furnish information in separate Annexures as per the enclosed proforma for each type of payment indicated in item (a) above, viz, interest, dividends etc. including the pay-
ments on which no tax has been deducted on the basis of certificate issued by a chartered accountant.
5. Details of tax deducted and paid to the credit of the Central Government
S . No . S e ct io n C o d e A mo u n t D e du c te d Tra n sf e r Vo u c he r / C ha l la n N o. g iv e n b y Ba n k D a t e o f Tra n s f e r V o u ch e r / B a nk B ra n ch C o d e
(1 1 5 ) (11 6 ) (1 1 7 ) (1 1 8 ) (1 1 9) (1 2 0 )
C h a l la n

T ot al

N o t e - W he r e d e d u ct i on i s ma d e b y o r on b e h al f of t h e G o ve rn m e n t , t o g i ve p a rt i cu la r s o f t r an s f e r vo u ch e rs ; ot h e r d e d uc t o rs t o g iv e p a rt i cu l a rs o f ch a ll

an no. re g a rd i ng d e po s it i nt o b a n k. VERIFICATION
I, _________________________________________________________, hereby certify that all the particulars furnished above are correct and complete.

Signature ofPlace
person: responsible for deducting tax at source _____________________________________________________________________
Name and designation of person responsible for deducting tax at source __________________________________________________________
Date :
___________________
* If address has changed give changed address in column 1(b)
 Annexure
Annexure - -

Details
Details of............................................................1
of............................................................1 paid
paid // credited
credited during
during the
the financial
financial year
year and
and of
of tax
tax deducted
deducted at
at source
source under
under section2
section2 of
of Income-tax
Income-tax Act
Act 1961
1961 :-
:-

Ded uc te e Pe rm a n en t Ac D co
a t un
e t of N um f u brneirsheiRe
Nam ngas on f or
a nd A d non-
dr e ss o f De d u cte e (A d Adrmoe ssu n t p ay a bl e Da te o n wh i ch R at e at Wh e th e r A mo u n t of t aDxa t e o n wh i ch Dt aatxe o n w h ic h t a xB a nk B ra n ch C o d e
nu m be(Pr AN
g ive
) no f Tax d denduc
de d uDcte edue ct i o nne e lower o t t ion
b e / gi ve n i f P A N i s mebe n tf io
o re
n e d e d uc t io n a mo u nt pa id / w hic h g ro si n g u p isd e d uc t e d d e d uc t e d p a i d t o t h e cre d it o f
C o de 3 deduc t ion
by b an k Ce r t if i ca t e o f ta x cr e di t e d tax (R s. )
d) re q u ir e d 4 Ce n t ra l Go ve rn m e nt 5
if an y6 d e d u ct e d

(1 ) ( 1 2 ) ( 1 3 )( 2) (1 4 ) ( 3) ( 4 ) ( 5) (6 ) ( 7 ) ( 8 ) ( 9) ( 1 0 ) (1 1 )

C h all an

Notes : -

1 Please state the nature of payment viz. interest, dividends.

2 Please use separate Annexures for deductions made under different sections.
3 Please enter Deductee Code 01 for companies, 02 for 'other than companies'.
4 Write Y for Yes and N for No.
5 Where deduction is made by or on behalf of the Government, transfer voucher number may be entered in column (9).
6 Write 'A' if deduction is made at
7 If necessary, a lower
please use rate deduction
additional or no
sheets tax deducted
to give is on
full details account of
of payment in athe
certificate under Please
above format. sectionalso
197 give
or 195 or write
running 'B' if
serial on account
number to all of certificate issued by a chartered accountant.
pages.

Signature
Signature of
of person
person responsible
responsible for
for deducting
deducting tax
tax at
at source____________________________________________________________________________
source____________________________________________________________________________
Name
Name and
and designation
designation of
of person
person responsible
responsible for
for deducting
deducting tax
tax at
at source_________________________________________________________________'.
source_________________________________________________________________'.