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

Name PAN
Flat/Door/Block No. Name of Premises/
Building/Village
Road/Street/Post Office Area/Locality
Town/City/District State Pin Code
E-mail Address STD code and Phone
Number ( )
1. Designation of Assessing Officer (Ward/Circle)
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)
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)
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)
PART-B
ASSESSMENT
JURISDICTION AND
FILING STATUS
Status (Tick)
(i) Individual
(ii) Hindu undivided family
(iii) Company
(iv) Firm
(v) Cooperative Society
(vi) Local Authority
(vii) Association of persons
Body of individuals not
covered by (v) or (vi)
PART-A
PERSONAL INFORMATION
PART-C
PARTICULARS OF INCOME DISCLOSED AND
PAYMENT OF ADDITIONAL TAX AND INTEREST
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 designation] 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