Form No. 61
[See third provision to clause (a) of rule 114C]

 Form of Declaration to be filled by a person who does not have either a Permanent Account Number (PAN) or General Index Register (GIR) No. and who makes payment in cash in respect of transaction specified in clauses (a) to (h) of rule 114B

1. Full name and address of the declarant ___________________________________________________________

______________________________________________________________________________________________

____________________________________________________________________________

2. Particulars of transaction  ______________________________________________________

3. Amount of transaction       ______________________________________________________

4. Details of documents being produced in support of address in column(1)

I hereby declare that my source of income is from agriculture and I am not required to pay income-tax on any other income if any.

Date :   ___________
Place :  ___________                                                                             Signature of the declarant

VERIFICATION

I, _____________________________________ do hereby declare that what is stated above is true to the best of knowledge and brief.

Verified today, the ____________ day of ____________, 20 _____

Date :   ___________
Place :  ___________                                                                             Signature of the declarant

Instructions:

Documents which can be produced in support of the address are :

(a) Ration Card
(b) Passport
(c) Driving license
(d) Identity Card issued by any institution
(e) Copy of the electricity bill or telephone bill showing residential address
(f) Any document or communication issued by any authority of Central Government, State Government or
     Local bodies showing residential address
(g) Any other documentary evidence in support of his/her  address given in the declaration