Single Copy (to be sent to the ZAO) Tax Applicable (Tick One)*

CHALLAN NO./ ITNS 280

Permanent Account Number

(0020) INCOME-TAX ON COMPANIES (CORPORATION TAX) (0021) INCOME TAX (OTHER THAN COMPANIES)

Assessment Year 2 0 1 2 1 3

X Y Z P R 9 3 9 3 A Full Name R A J A R A J V I R R A Complete Address with City & State 5 W E S T P U N J A B I D E L H I Tel. No. 1 1 1 1 1 1 1 Advance Tax (100) Self Assessment Tax (300) Tax on Regular Assessment (400)
DETAILS OF PAYMENTS

K U M A R N E W D E L H I Pin 1 0 0 0 2 6

B A U G H

Type of Payment (Tick One) Surtax (102) Tax on Distributed Profits of Domestic Companies (106) Tax on Distributed Income to Unit Holders (107 Amount (in Rs. Only) 1 9 4 5 0 8 0 2
FOR USE IN RECEIVING BANK

Income Tax Surcharge Education Cess + SHEC Interest Penalty Others Total Total (in words)
CRORES LACS THOUSANDS HUNDREDS

Debit to A/c / Cheque credited on D D M M Y Y SPACE FOR BANK SEAL

1
TENS

8
UNITS

NINETEEN NINE EIGHT TWO 676767 Paid in Cash/Debit to A/c /Cheque No. Dated 7/30/2012 ICICI BANK Drawn on (Name of the Bank and Branch) Date: 7/30/2012 Signature of person making payment Rs. 1 9 9 8 2

Taxpayers Counterfoil (To be filled up by tax payer) X Y Z P R 9 3 9 3 Received from RAJA RAJVIR RAJKUMAR (Name) Cash/ Debit to A/c /Cheque No. 676767 For Rs. 19,982 Rs. (in words) Nineteen Thousand Nine Hundred Eighty Two ICICI BANK Drawn on
PAN on account of Income Tax on Type of Payment for the Assessment Year

SPACE FOR BANK SEAL A

(Name of the Bank and Branch) Companies/Other than Companies/Tax

(Strike out whichever is not applicable) (To be filled up by person making the payment)

Rs.