FORM DA
APPLICATION FOR SETTLEMENT OF CASES
(See section 22C of the Wealth-tax Act, 1957 and rules 4A and 4AA of the Wealth-tax Rules, 1957)

In the Settlement
Commission
at ................... Bench
Settlement Application
No. .........20.....20.........
Name PAN
Flat/Door/Block No. Name of Premises/ Building/Village Status (Tick)

(i) Individual
Road/Street/Post
Office
Area/Locality (ii) Hindu undivided family
State Pin Code (iii) Company
Town/City/District
E-mail Address
PART-A
PERSONAL
INFORMATION
STD code and Phone
Number ( )
1. Designation of Assessing Officer (Ward/Circle)
2. The Commissioner having jurisdiction over the applicant
3. Assessment years in connection with which the application for settlement is made and the date of filing the return of income
PART-B
ASSESSMENT
JURISDICTION
AND FILING
STATUS
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 yearwise)
3. Full and true disclosure of wealth which has not been disclosed before the Assessing Officer. (Assessment year-wise)
4. The additional amount of wealth-tax payable on wealth referred to in (3). (Assessment yearwise)
5. Interest payable. (Assessment year-wise)
6. Total of (5) and (6)
PART-C
PARTICULARS
OF INCOME
DISCLOSED
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 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 22A of the Wealth-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 22C(1) of the Wealth-tax Act, 1957
1. Amount of wealth which has not been disclosed before the Assessing Officer (same as in Part-C, item 3 of the application)
2. Additional amount of wealth-tax payable on the said wealth
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 wealth referred to item No. l has been derived. (Assessment year-wise)
Place
Date Signature of Applicant