To

MCS Limited, '

(Unit : Sardar Sarovar Narmada Nigam Limited)101, Shatdal Complex, Opp. Bata Show Room, Ashram Road, Ahmedabad - 380 009.Phone : 079 - 2658 2878 - 80 (3 lines), 2658 4027 Fax : 079 - 2658 1296Email : ssnnl2008@gmail.com

Dear Sir,Sub :- Redemption of SSNNL Deep Discount Bonds.

(1) The following duly discharged Deep Discount Bond Certificate(s) are enclosed herewith for redemption.

Folio No. DDB GertificateNo.

Districtive Nos. Number ofBondsFrom lo

(A separate sheet may be attached if required)

Change of address of Sole/First holder (if any)

Pin Code No.(3)

(2)

City

(4)

(5)

Date:Place

lncome Tax Deduction Status :

(a) Form 15 G in duplicate (Form

:

lI Exempted f, Non exempted15G Enclosed. Kindly fillup the necessary details and send it to us.)

Bank details :

Bank Account Tvpe f] Savinqs n Current

Bank Account NumberName of the BankBank address

CityPIN Code

9 digit MICR Code No.(Enclose copy of the cancelled cheque )

Third HolderSole/First Holder

Enclose photo

copy of PAN Card

Signature of the Sole/First Holder

For the use of Registrars :

Date of Receipt lnward No. Date of entry Remarks

Folio No. have to be written properly in all enclosure to this proforma.

Signature required at the back of the bond and wherever required.Note : 1.'2

FSRtul Fdffi, 15GtSee section 197A(lC), 197A(1A) and rLile 29Cl

Declaration under section 197A(1) and section 197A (iA) of the InconTe-tax Act, 1961 to be made by an individual or Person (not being a conrpany or firm)claiming {ertain receipts without deduction of tax,

PART - X

1l Name bf Assessee (Declareant) : 2] PAN :

3l Assessment Year ?0n 6-17

6l Status :

4l Flal / Door / Block No, 5l Name of Premises : 7l Assessed in

which Ward / Circle

8l Road / Slreet / Lane : 9l Area i Locality :101 A0 Code (whorn assessed last time)

Area Code AO Type Range Code AO l,,lo.

lil Town i City / Distrid : 121 State :

141 Last Assessment Yearin which assessed :

2t)15-16131 PrN

151 Email 161 Telephone I Mobile No : 171 Present Ward'l Circle

181 Residential Status : Reident

191 Narne af Business / Occupation :

201 Present AO Code (if not same as above):

211 Jurisdictional Chief Camm, of Incorne Tax or Comm. ofIncorne Tax {if not assessed to income tax earlier):

Area Code AO Type Range Code AO No.

221 Estimated total income from the sources mentioned below: (Please tick the relevant box)

Dividend from shares referred to in Schedule - iinterest on securities referred to in Schedule - II

Interest on surns referred to in Schedule - III vIncorne from units referred to in Scheduie - IV

The amt of withdrawai referred in sec-B0CCA{2Xa) from National Savings ftheme referred to in Schedule - V

231 Estimated total incorne of the previous year in lncsme mentioned in Col - 22 to be included :

241 Details of investments in respect of which the declaration is being made :

SCHEDULE.T

(Details of shares, which stand in the name of the declarant and beneficially owned 9y ltm)No. of

shares

Class of shares & face

value of each share

lotal value

of shares

Distinctive numbers

of the shares

Date on which the shares were acquired

by the declarant (dd/mm/yyyy)

SC}IEDULE-II

{Details of the securities held in the name of declarant and beneflcially ownqd by !im)Date(s) on which the securitues were

acquired by ceclarant (dd/mmiyyW)

Dateis) of

securi lies 4dd/mm/VWV)

, SCf{fDULffi.IIg

(Details of the sums given by the declarant on intei"est)

Name and address of the person io

whr:n the surns are given 0n interest

Amount of sums

given on inters;t

Date on l',rhich sumsgiven

on interest{dd/mmlww)

Period for which sums

r,vere given on interesf

R.ate of

interest

$ce{Epii{"H- E'[f

iDei*iis *f ihe mutual i;rrd units held !n the nrme cf deciarant and benefieiaily on'ned by hirri)

iun:e *nri ;irldress of tn*

rn*iual iund

Class oi units & faie

value af each u*it

Distinctive i

numher

pf units

SCHEDULE.V

(Details of the withdrawal made from National Savings Scheme)

Particulars of_the Post Office where the account under the

National Savings Scheme is maintained and the account number

Date on which the account

was opened (dd/mm/yyyy)

The amount of withdrawal

frorn the account

Signature of the Declarant

Declaration / Verification

*I/ We do hereby declare that to the best of

knowledge and belief what is stated above is correct, complete and truly stated. *I Affe declare that incomes referred to inthis form are not includible in the total income of any other person u/s 60 to 64 of Income Tax Act, 1961. xIAVe further,

declare that tax *on my I our estimated totai income, including *income / incomes referred to in column 22 above,

computed in accordance with provisions of the Incorrre Tax Act 1961. for the previous year ending on 31.03.2015 relevantto the relevant to the assessment year 2016-17 will be nil,xI I We also, declare that xmy / our xincome / incomes referred to in Column 22 for the previous year ending on

31.03.2016 relevant to the assessment year 2016-17 will not exceed the maximum amount which is not chargeable toincome tax.

Signature of the DeclarantPlace :

Date :

PART - IIFor use bv the to whom the declaration is

il Name of the person

in Column 22 of Part tr

responsible for paying the income referred to 2l PAN of the person indicated in Column 1 of Paft II

3l Complete Address : 4l TAN of the person indicated in

Column 1 of Part II :

5l Email : 6l Telephone / Mobile ltlo : 7l Status :

8l Date on which Declaration is

Furnished (dd/mni/yyyy) :

9l Period in respect of which thedividend has been declared or theincome has been paid / credited :

101 Amount ofincome paid :

111 Date on which the income has

been paid I credited(dd/mm/yyyy) :

121 Date of declaration, distribution or payment ofdividendlwithdrawal under the Nationa! Savings

Scheme{dd/mm/yyyy) :

13.l Aecount Number of National Saving

withdrawal has been made :

Scheme from which

Fcrwarded tc the Chief Commissioner or Cornmissloner of income-tax

Plac* :

Dar,r

II

I

I_l

.$rgnaft,L"e *f the person respanstble far paying the

jnrrr?s referred ta in Cr:lunn ?1 *f Fart I