ANNEXURE
STATEMENT OF PARTICULARS
PART A-GENERAL

1. Name of the fund or trust or institution or any university or other educational institution or any hospital or other medical institution.
2. Address
Flat/ Door/ Block No.*
Name of Premise/ Building/ Village
Road/ Street/ Post Office
Area/ Locality*
Town/ City / District*
State*
Pincode*
3. Permanent Account Number
4. Assessment Year*
5. Sub-clause of section 10(23C) under which the fund or trust or institution or any university or other educational institution or any hospital or other medical institution is seeking exemption.*
6. Number and date of notification/approval of the fund or trust or institution or any university or other educational institution or any hospital or other medical institution.
S.No. Number of notification /approval Date of notification/approval
1
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PART B - APPLICATION OF INCOME FOR CHARITABLE OR RELIGIOUS OR EDUCATIONAL OR PHILANTHROPIC PURPOSES
7. Nature of charitable/ religious/ educational/ philanthropic activity [as referred to in sub-clauses (iv),(v),(vi) or (via) of section 10(23C)]*
8. Total income of the previous year of the fund or trust or institution or any university or other educational institution or any hospital or other medical institution *
9. Amount of income of the previous year applied during the year wholly and exclusively to the objects for which it is established *
10. Amount of income of the previous year accumulated for application, wholly and exclusively,
to the objects for which it is established,to the extent it does not exceed 15% of income of that year. *
11. Amount of income, exceeding 15% of income of the year, accumulated in accordance with clause (a) of the third proviso to section 10(23C). *
12 (a) Whether, during the previous year, any part of the income, not exceeding 15% of income accumulated in any earlier year, was applied for purposes other than to the objects for which it is established or has ceased to be accumulated for application thereto?*
(b) If the answer to (a) above is 'yes', then give details of income so applied or ceased to be so accumulated
13 (a) Whether, during the previous year, any part of the income of any earlier year exceeding 15% of the income, that was accumulated in accordance with clause (a) of the third proviso to section 10(23C) in that year, was applied for purposes other than to the objects for which it is established or has ceased to be accumulated for application thereto?*
(b) If the answer to (a) above is 'yes', then give details of income so applied or ceased to be so accumulated
14 (a) Whether, during the previous year, any part of the income of any earlier year exceeding 15% of the income, that was accumulated in accordance with clause (a) of the third proviso to section 10(23C) in that year, was not utilised for purposes for which it was accumulated during the period for which it was to be accumulated?*
(b) If the answer to (a) above is 'yes', then give details thereof, together with amount of income not so utilised.
PART C - OTHER INFORMATION

15 (a) Whether any funds, other than the assets or voluntary contributions referred to in clause (b) of the third proviso to section 10(23C), were invested or deposited for any period during the previous year, otherwise than in the forms and modes specified in sub-section (5) of section 11. *
(b) If the answer to (a) above is 'Yes' then give the details as under:
S.No Nature of investment or deposit Amount invested or deposited Period of investment or deposit
1
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16 In relation to any income being profits and gains of business, -
(a) whether the business was incidental to the attainment of the objectives of the fund or trust or institution or university or other educational institution or hospital or other medical institution? *
(b) whether separate books of account were maintained in respect of such business? *
(c) if the answer to (a) and/or (b) above is 'no', then state the amount of such income.
17 (a) whether during the previous year, any part of the accumulated income was paid or credited to any trust or institution registered under section 12AA or to any fund or trust or institution or any university or other educational institution or any hospital or other medical institution referred to in sub-clause (iv) or sub-clause (v) or sub-clause (vi) or sub-clause (via) of clause (23C) of section 10? *
(b) If the answer to (a) above is 'yes', then give details thereof, together with amount of income so paid or credited.
18 (a) Whether any voluntary contribution, other than voluntary contribution in cash or voluntary contribution of the nature referred to in clause (b) of the third proviso to section 10(23C), was held during the previous year, otherwise than in any of the forms or modes specified in sub-section (5) of section 11, after the expiry of one year from the end of the previous year in which such voluntary contribution was received?*
(b) If the answer to (a) above is 'yes', then give details thereof, including the amount of such voluntary contribution
19 (a) whether any anonymous donation referred to in section 115 BBC was received during the year? (See notes 2 &3)*
(b) If the answer to (a) above is 'yes', then state the amount of such anonymous donation.

The prescribed particulars are annexed herewith:
Place:* Name:*
Date:* Membership No.:*
FRN (Firm Registration Number):
Address:*