FORM NO. 13D
[See rule 28(4)]
Application for a certificate under section 194G(2) of the Income-tax Act, 1961, relating to deduction of income-tax from payments of commission, etc., made to persons who are or have been stocking, distributing, purchasing or selling lottery tickets 
To,
The Assessing Officer,

Sir,

I
		[name] 
of 							do hereby declare that 
	[address] 
my total income (including income comprised in payments of the nature referred to in section 194G of the income-tax Act, 1961) computed in accordance with the provisions of that Act for the previous year relevant to the assessment year 19     19     *was less than the minimum liable to income-tax     and I have no reason to expect that my 
	amounted to Rs……………………
totalincome (computed as aforesaid) for three assessment years next following will increase substantially. 
2. I, therefor, request that a certificate may be issued to the person(s) responsible for paying income by way of commission, remuneration or prize (by whatever name called) on the sale of lotttery tickets, particulars of which are given in the Schedule hereto, authorising him/them not to deduct income- tax                                                          .   
	to deduct income -tax at the rate of                    per cent    
at the time of credit of such income to my account or, as the case may be, payment thereof to me. 
3. I hereby declare that what is stated in this application is correct.

Date                          	                                                      .
	Signature 
							Address                                      	
			Permanent Account Number                                                   .  

SCHEDULE 
Sr. No.	Name and addresss of person(s) responsible for paying commission, remuneration or prize (by whatever name called) on the sale of lottery tickets	Amount of *commission/remuneration/prize 	

			

Date                              				                                                    ,
*Score out whichever is not applicable.				Signature