(See rule 41)
Claim for refund of tax
I, ____________________ of ____________________ do hereby state that my total income computed in accordance with the provisions of the Income Tax Act, 1961, during the year ending on _____________ being the previous year for the assessment year commencing on the 1st April, ___________________ amounted to ` __________ that the total income tax chargeable in respect of such total income is ` __________ and that the total income tax paid, or treated as paid under Section 199, is `_________________
I, therefore, request for a refund of ` ___________
I hereby declare that I was resident/resident but not ordinarily resident/non-resident during the previous year relevant to the assessment year to which this claim relates and that what is stated in this application is correct.