FORM NO. 63A
[See rule 12B]
Statement to be furnished to the Assessing Officer designated under rule 12B of the Income-tax Rules, 1962, in respect of income distributed by a Mutual Fund
(Separate forms to be filled up for each scheme)

1. Name of the Mutual Fund and the address of registered office
2. Permanent Account Number
3. Previous Year ending
4. Names and addresses of the trustees of the fund
5. Objects of the fund (Enclose a copy of the Mutual Fund deed)
6. Whether registered with SEBI;
If yes, please specify the date and number of the order (Enclose a
copy of the SEBI’s order)
7. Date of inception or setting up of the Mutual Fund
8. Details of Asset management company such as names and
addresses of Directors
9. Name of Scheme
10. Face Value of Unit
11. Total No. of Units
12. Details of income distributed :-
Distribution or Payment of
Income
Tax payable under
section 115R
Interest chargeable
under section 115S, if
any
Payment towards tax and interest
under section 115S (Attach a copy of
challans)
Date(s) Amount(s) Date(s) Amount(s)
13. Tax payable on income distributed to the Unitholders
Enclose audited accounts including balance sheet, annual report, if any, with certified copies of income and appropriation towards distribution of income.
I, _____________________________________________________________ (Name in full and in block letters) 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(s), including the documents accompanying such Annexure(s), is correct and complete. I further declare that I am furnishing such statement in my capacity as _________________________________ (designation) and that I am competent to furnish this statement and verify it.
Verified today the ________________ day of ________________
Place Signature
Verification
I/We ________________________________________________ have examined the books of account and other documents
showing the particulars of income earned and the income distributed to the unit holders by the
___________________________________________________ (name of the Mutual Fund) for the previous year ending
________________________.
2. I/We declare that the above particulars are true and correct to the best of my/our knowledge and belief.
_________________________________
Place _______________ (Signature with name of the Accountant)
Date ________________
Note 1 : “Accountant” means the accountant as defined in the Explanation to sub-section (2) of section 288 of the Income-tax
Act, 1961.