FORM NO. 13
[See rule 28(1)]
Application by a person for a certificate under section 197 of the
Income-tax Act, 1961, for no deduction of tax or deduction of
tax at a lower rate
To
The Assessing Officer,
……………………….
……………………….
……………………….
I, ......................................…………………………of ........................................ do hereby, request that a
certificate may be issued to the person responsible for paying to me the income by way of salary/ interest on
securities/interest other than “interest on securities”/insurance commission/dividends /rent /income in    respect
of  units (strike out whichever is not applicable) authorising him not to deduct income-tax/to deduct
income-tax at the rate of ............................... per cent at the time of payment to me of such income. The
particulars of my income are as under:
(i) Status (state whether individual, HUF, firm, BOI, etc.)
(ii) Residential status (whether resident/resident but not ordinarily resi-
dent/non-resident)
(iii) Permanent Account Number, if any
(iv) Assessment year to which the payments relate
(v) Estimated total income of the previous year relevant to the assess-
ment year referred to in (iv) above
(v) Total tax payable on the income at (v)
(vii) Average rate of tax
Col.(vi)
 x 100
Col.(v)
(viii) How the liability determined in col.  (vi)  is proposed to be  dis-
charged ?(Specify the amount to be paid by way of advance tax
and TDS)
(ii) Total income assessed in the last three assessment years and the
total tax paid for each such year:
 Total
 Total
income
 tax
(i)
(ii)
(iii)
(x) Date and amount of advance tax and TDS, if any, already paid so
far.
(xi) Details of  income claimed to be exempt and not included in the total income
(please append a note giving reason for claiming such exemption).
(xii) Please furnish the particulars in the Schedules below in respect of the payments for which the
certificate is sought:

SCHEDULE I
Description of Number of Date of Amount of
securities securities securities securities
(1) (2) (3) (4)
SCHEDULE II
Sl. No. Name and Amount of The date on Period for Rate of
address of such sum which such which such interest
the person
 sums were sums were
to whom the
 given on given on
sums are
 interest interest
given on
interest
(1) (2) (3) (4) (5) (6)
SCHEDULE III
Sl. Name and address of person responsible for Amount of insurance
No. paying insurance commission commission
(1)
 (2)
 (3)
SCHEDULE IV
Sl. No. Name and No. of Class of Total face Distinctive
address of shares shares and value of Nos. of
the
 face value of shares shares
company
 each share
(1) (2) (3) (4) (5) (6)

SCHEDULE V
Sl.No. Name and Period of Amount Income Income Total
address of employ- of salary from from income
the ment received house sources
employer
 property other than
salary and
income
from
house
property
(1) (2) (3) (4) (5) (6) (7)
SCHEDULE VI
Sl. Name and address of person responsible Amount of
No.
 for paying rent
 rent
(1)
 (2)
 (3)
SCHEDULE VII
Sl. No. Name and Number. of Class of units Total face Distinctive
address of units and face value of Nos. of
the mutual
 value of each units units
fund
 unit
(1) (2) (3) (4) (5) (6)
*I, ......................................……………… the trustee/co-trustee of ......................................…… do hereby
declare that the securities/sums/shares, particulars of which are given in the Schedules above, are property
held under trust wholly for charitable or religious purposes and that the income therefrom qualifies for
exemption under sections 11 and 13 of the Income-tax Act, 1961.

*I declare that the securities/sums/shares, particulars of which are given in the Schedules above, stand in
my name and are beneficially owned by me, and the income therefrom is not includible in the total income
of any other person under sections 60 to 64 of the Income-tax Act, 1961.
I further declare that what is stated in this application is correct.
 ………………………….
(Signature)
Date ....................
 ……………………….
Place ...................
 ……………………….
……………………….
(Address)
*Strike out whichever is not applicable.