E-Payment Request Form Full Name: _______________________________ Address: PAN No. / TAN: Assessment Year: Major Head Type of Payment (100) ADVANCE TAX (106) TAX ON DISTRIBUTED PROFITS (107) TAX INCOME (300) SELF ASSESSMENT TAX (200) TDS / TCS Payable by Taxpayer (0034)
E-Payment Request Form Full Name: _______________________________ Address: PAN No. / TAN: Assessment Year: Major Head Type of Payment (100) ADVANCE TAX (106) TAX ON DISTRIBUTED PROFITS (107) TAX INCOME (300) SELF ASSESSMENT TAX (200) TDS / TCS Payable by Taxpayer (0034)
E-Payment Request Form Full Name: _______________________________ Address: PAN No. / TAN: Assessment Year: Major Head Type of Payment (100) ADVANCE TAX (106) TAX ON DISTRIBUTED PROFITS (107) TAX INCOME (300) SELF ASSESSMENT TAX (200) TDS / TCS Payable by Taxpayer (0034)
Please find enclosed Cheque Number _____________ on our Current Account 1. Tax Amount: ________________ No.______________________ Amounting to Rs._______________________ 2. Surcharge: ________________ (Rupees________________________________________________________) 3. Education Cess: ________________ towards CBDT e-Payment. 4. Interest: ________________ 5. Penalty: ________________ We confirm that any discrepancy in the Challan, if any, will be brought to the notice of the Bank within one working day for any rectification. 6. Others: ________________
Total: ________________ Authorised Signatory
For Branch Use Only
Challan Identification Number (CIN): ______________________________________________
Name of the Designated Officer: __________________________ Signature:_______________