FORM G
Certificate quantifying amount of income-tax on withdrawal consequent upon closure of account
[See paragraph 12(2)]
Office of the Commissioner of Income-tax

Deposit Account No.
Name of depositor
Permanent Account No.
The depositor above named wishes to close his Deposit Account No. I hereby certify that out of his share of the balance lying to the credit of his account, an amount of Rs. is payable by way of income-tax and the same should, therefore, be deposited by the deposit office before the balance left is transferred to the depositor's designated account.

Date :
Signed
Seal: Designation of Assessing Officer