FORM D
[See sub-paragraph (3) of paragraph 9]
(To be submitted in duplicate)

[Name of the Deposit Office]
Serial No.

Details regarding the manner and extent of utilisation of the amount withdrawn from account under the Capital Gains Accounts Scheme, 1988
To
The Manager
[Name and address of the Deposit Office]
I, [Name of the applicant/Depositor], son of
residing at [Address] am furnishing in terms of sub-paragraph
(3) of paragraph 9, the requisite details regarding the manner and extent of utilisation of the amount of Rs. [in figures] (Rupees ) [in words] withdrawn by me on [date] out of the balance to the credit in account-A No.(Pass book No.) maintained with your office in my name/ in the name of aforesaid
[mention the name and address of the depositor]
2. Manner/purpose for which amount withdrawn, mentioned here in above has been utilised :
Purpose Amount Party to whom payment has been made
Voucher No. Receipt
No.(with date)
Rs. P.
3. I hereby declare and confirm that the amount withdrawn, which is mentioned here in above has been utilised partly and the balance of Rs. was redeposited on
to the credit of aforesaid account/ wholly, for the purpose mentioned here in after under column 2.
4. This declaration is made by me on behalf of the aforesaid minor depositor
of whom I am guardian.
5. This declaration is made by me on behalf of the aforesaid firm/ company/ association of persons/ body of individuals of whom I am the authorised officer to make this declaration.
6. This declaration is made by me as karta of the aforesaid Hindu undivided
family.
Signature/Thumb impression of the Depositor/the
Guardian/Karta/Authorised Officer of the Depositor
Date : .
Place : . Additional specimen
PAN and Distt./Ward/Circle/Range where assessed
FOR THE USE OF DEPOSIT OFFICE
Withdrawal of Rs. permitted/ not permitted as the details in respect of
total amount of Rs. withdrawn on have not been furnished.
Applicant/ Depositor has been advised to furnish the details.
Date : .

Officer-in-charge
Notes:
1. Delete whatever is not applicable.
2. Columns 4, 5, 6 pertain to deposits made on behalf of a minor, firm, company, a Hindu undivided family, association of persons, body of individuals. Hence, individual depositor may score out these columns and in other cases only one column which is applicable may be retained and the remaining columns may be
scored out.
3. If space provided under column 2 is not sufficient to furnish the requisite details, same may be furnished by way of using separate enclosure and referring to the same under the respective column.