Single(Copy to be sent the ZAO)		
			Tax Applicable(Tick One)*						
	CHALLAN NO./		(0020) INCOME-TAX ON COMPANIES				Assessment Year		
	ITNS		(CORPORATION TAX)						
	280		(0021) INCOME TAX 	a			2013-14		
			(OTHER THAN COMPANIES)						
	Permanent Account Number			
				
	Full Name			
	 		
	Complete Address With City and State			
			
	Tel. No.		Pin	110092		
						
	Type of Payment(Tick One)		
	Advance Tax(100)	a	Surtax(102)				
	Self Assessment Tax (300)		Tax on Distributed Profits of Domestic Companies(106)				
	Tax on Regular Assessment(400)		Tax on Distributed Income to Unit Holders(107)				
	DETAILS OF PAYMENTS	Amount(in Rs.only)			FOR USE IN RECEIVING BANK		
	Income Tax	300000			debit to A/c /Cheque Credit on 		
	Surcharge	0					
	Education Cess 	9000			DD        MM        YY		
	Interest	0			SPACE FOR BANK SEAL		
	Penalty	0					
	Others	0					
	Total	309000					
	Total(in words)						
	CRORES	LACS	THOUSANDS	HUNDREDS	TENS	UNITS					
		THREE	NINE								
											
	Paid in Cash/Debit to Ac/Cheque No		Dated						
									
	Drawn on	  				
(Name of Bank and Branch)					
						
Date	01/12/2012	Signature of person making Payment		Rs.		
			
Taxpayers Counterfoil(To be Filed up by the tax payer )	SPACE FOR BANK SEAL		
	PAN	AADPT4109Q				
	Received Form		 		
	Cash/Debit to Ac/Cheque No		For Rs.	309000			
	Rs in Words	THREE LAKH  NINE THOUSAND Only	 		
	Drawn on	   	 		
		(Name of the Bank and Branch)			
	On Account of  	Other than Companies				
	Income Tax on		 			
	Type of Payments	Advance Tax			
	for the Assessment Year 	2013-14	Code	T0221	Rs.