Printed from www.taxmann.com FORM NO. 64 [See rule 12C] Statement of income distributed by Venture Capital Company or a Venture Capital Fund to be furnished under section 115U of the Income-tax Act, 1961 1. Name of the Venture Capital Company or Venture Capital Fund and the address of registered office 2. Permanent Account Number 3. Previous year ending 4. Name and address of the Directors of the Venture Capital Company/trustees of the Venture Capital Fund 5. Total income under all heads received from the investments in Venture Capital Undertakings (6+8+10+12) 6. Total income received from the investments in Venture Capital Undertakings under the head 'Long-term Capital Gains' 7. Proportion of (6 to 5) 8. Total income received from the investments in Venture Capital Undertakings under the head 'Short-term Capital Gains' 9. Proportion of (8 to 5) 10. Total Dividend income received from the investments in Venture Capital Undertakings 11. Proportion of (10 to 5) 12. Other income (such as interest etc.) received from the investments in Venture Capital Undertakings 13. Proportion of (12 to 5) 14. Details of persons receiving income from the Venture Capital Company or the Venture Capital Fund in the following format : S. No. Name(s) Address(es) PAN Circle/ Ward/ Special Range where assessed to Income-tax Total amount paid Amount paid under 'Long Term Capital Gains' Amount paid under 'Short Term Capital Gains' Amount paid as 'dividend' Other Income such as interest etc. paid [Column 6× Sl. No. 7] [Column 6× Sl. No. 9] [Column 6× Sl. No. 11] [Column 6× Sl. No. 13] (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Enclose a copy of the Certificate of Registration under the Securities and Exchange Board of India Act, 1992. Enclose a copy of the Venture Capital Fund deed in case of Venture Capital Fund registered under the provisions of the Registration Act, 1908. Enclose audited accounts including balance sheet, annual report, if any, with certified copies of income and appropriation towards distribution of income. Printed from www.taxmann.com 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 investors by the _______________________________________________ (name of the Venture Capital Company or the Venture Capital 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.
