FORM NO.

15CA Acknowledgement
[See rule 37BB] Number
Information to be furnished for payments, to a non-
558675231040719
resident not being a company, or to a foreign company
x
PART A - To be filled up if the remittance is chargeable to tax under the provisions of the Income-tax Act,1961 and
the remittance or the aggregate of such remittances, as the case may be, does not exceed five lakh rupees during the
financial year.
PART B - To be filled up if the remittance is chargeable to tax under the provisions of the Income-tax Act,1961 and
the remittance or the aggregate of such remittances, as the case may be, exceeds five lakh rupees during the financial
year and an order/ certificate u/s 195(2)/ 195(3)/ 197 of Income-tax Act has been obtained from the Assessing Officer.
PART C - To be filled up if the remittance is chargeable to tax under the provisions of Income-tax Act, 1961 and the
remittance or the aggregate of such remittances, as the case may be, exceeds five lakh rupees during the financial year
and a certificate in Form No. 15CB from an accountant as defined in the Explanation below sub-section (2) of section
288 has been obtained.
PART D - To be filled up if the remittance is not chargeable to tax under the provisions of the Income-tax Act,1961
{other than payments referred to in rule 37BB(3)} by the person referred to in rule 37BB(2).
x
Please select the relevant part from the drop down. PART - D
x
PART - D
To be filled up if the remittance is not chargeable to tax under the provisions of the Income-tax
Act,1961 {other than payments referred to in rule 37BB(3)} by the person referred to in rule 37BB(2).
REMITTER
Name of Remitter GEMOETRIX ROBOTS INDIA PRIVATE LIMITED
PAN of the Remitter (if available) AAGCG6612F
TAN of the Remitter (if available)
ADDRESS OF THE REMITTER
Flat/ Door/ Block No GAT NO- 53/1
Name of premises/ Building/ Village NA
Road/ Street NEAR TALAWADE CIRCLE, TALAWADE
Area/ Locality TALAWADE
Town/ City / District PUNE
State MAHARASHTRA
Country INDIA
Pin Code 411062
Email ID PRAFULKHACHANE@GEOMETRIXAR.COM
Phone Number 9921001880
Status of the Remitter COMPANY
Residential status of remitter Domestic company
REMITTEE
Name of recipient of remittance GLOBAL ROBOTS LTD
PAN of the recipient of remittance, if available
ADDRESS
Flat/ Door/ Block No 0
Name of premises/ Building/ Village BEANCROFT ROAD
Road/ Street MARSTON MORETAINE
Area/ Locality BEDFORDSHIRE
Town/ City / District BEDFORDSHIRE
State BEDFORDSHIRE
Country UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IREL
AND
ZIP Code 000000
Email ID ACCOUNTS@GLOBALROBOTS.COM
Phone Number
Country to which remittance is made
Country UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IREL
AND
Name of Country if selected as Others
Currency POUND STERLING
Currency if selected as Others
Country of which the recipient of remittance is UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IREL
resident, if available AND
REMITTANCE
Amount payable
In foreign currency: 18479.33
In Indian Rs. 1600185
Name of bank ICICI Bank Ltd
Name of Bank if selected as Other Bank
Name of the branch of the bank PUNE
BSR code of the bank branch (7 digit) 0000001
Proposed date of remittance (DD/MM/YYYY) 04/07/2019
Nature of remittance as per agreement/ document REIMBURSEMENT OF EXPENSES
Nature of remittance as per agreement/ document -
if Others
Relevant purpose code as per RBI Other Business Services
S1099 - Other services not included elsewhere

2. I certify that I have reason to believe that the remittance as above is not chargeable under the provision of
Income-tax Act 1961 and is not liable for deduction of tax at source.

PART-D VERIFICATION

1. I, PRAFULLAKUMAR KHACHANE(full name in block letters) son/daughter of BHASKAR KHACHANE in the

capacity of DIRECTOR (designation) solemnly declare that the information given above is true to the best of my
knowledge and belief and no relevant information has been concealed

2. In case where it is found that the tax actually deductible on the amount of remittance has not been deducted or after
deduction has not been paid or not paid in full I undertake to pay the amount of tax not deducted or not paid, as the
case may be along with interest due. I shall also be subject to the provisions of penalty for the said default as per the
provisions of the Income-tax Act, 1961

3. I further undertake to submit the requisite documents for enabling the Income-tax Authorities to determine the nature
and amount of income of the recipient of the above remittance as well as documents required for determining my liability
under the Income-tax Act, 1961 as a person responsible for deduction of tax at source.

Date (DD/MM/YYYY): 04/07/2019

Name of the person responsible for paying to non-resident PRAFULLAKUMAR KHACHANE

Place PUNE

Designation DIRECTOR
This form has been digitally signed by PRAFULLAKUMAR BHASKAR KHACHANE having PAN
AQOPK9267D from IP Address 103.203.61.108 on 2019-07-04 15:06:14.0 .
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Fertilizers and Chemicals Limited,C=IN