This is to state that

Name of the Applicant

1.

Particulars of the applicant:

(a)

Full name of the applicant

(b)

Permanent Account Number

(c)

Address of the applicant

(d)

Address for communication

(e)

Location(s) of the business enterprises in India

(f)

Email id and the contact numbers of the person with whom correspondence is required to be made

(g)

Names and designation of the authorised representatives who would be appearing before the authorities for negotiations of the APA

2.

Whether pre-filing discussions in respect of rollback were sought by the applicant? If yes, please furnish

(a)

Date of application for pre-filing meeting:

(b)

Date of pre-filing meeting(s) with the APA Team:

3.

Whether application in Form 3CED is being filed simultaneously:

4.

Details of international transaction(s) including Name(s) of the Associated Enterprises in respect of which rollback is requested for

5.

Whether the international transaction(s)  is  the same as that in respect of which APA request is being made in Form 3CED by the applicant

6.

Particulars of additional Fee paid by the applicant

Amount in Rs.
Challan No.
Dated:

7.

The details of previous years for which rollback is being sought

8.

Has the same international transaction been undertaken in any other year for which rollback is permissible but the same is not being requested for. If yes, the reasons for the same be provided

9.

Period of APA proposed along with the date from which APA is sought to be made applicable in the application in Form 3CED

10.

Whether return of income for all the previous years mentioned in 7 above have been furnished on or before the due date

Yes/No

11.

If yes, provide details including acknowledgement No. date of furnishing etc

12.

Whether audit report under section 92 E in respect of the international transaction referred to in 4 above for all the previous years mentioned in 7 above have been furnished on or before the due date

Yes/No

13.

If yes, provide details including date of furnishing etc.

14.

Details of pending proceedings including appeals for the years mentioned in 7 above  in respect of international transaction(s) mentioned in 4 above

15.

Whether Appellate Tribunal has disposed of any appeal in respect of international transaction mentioned in 4 above for any of the years mentioned in 7 above? if yes, then details may be provided

Place:

Date:

Applicant