FORM I
FORM OF DECLARATION
(To be filed in triplicate)

1. Name of the owner of the bank notes
                        (In block letter)
2. Address: Office Residence
3. Status, i,e., whether individual, Hindu undivided family, company, firm, etc.
4.        (a)  Whether assessed to income-tax;
(b) If so, name of the Income-tax Circle/Ward/District where last assessed;
(c)  Permanent Account Number.
5. If engaged in business, profession or vocation, name in which such business is carried on.
6. Principal place of business, profession or vocation, and location and style of each branch.
7. In the case of a firm, name and address of each partner.
8. In the case of partner in a firm, name and address of each firm or firms in which he is a  partner.
9. In the case of a salaried person, amount of salary per annum.
10. In the case of a Government employee, Government Department and post held.
11. In the case of retired Government employees, last post held, Government Department under which such post was held and date of retirement.
12. In the case of a retired employee of a non-Government employer, particulars of last post held.
13. In the case of any other person, particulars of profession or vocation or, as the case may be, former profession or vocation.
14. Particulars of high denomination bank notes tendered.
Denomination                                Number of Notes                       Distinctive Numbers*
Total value
Rs.1000
Rs.5000
Rs.10000                                                                                          Rs.          Rupees
 (in words)
*Distinctive numbers of bank notes tendered should be furnished indicating alphabetical and numerical prefixes of the notes.Attach a statement if space is not adequate.
15. Reasons for keeping the amount in cash in notes of such high denominations
16. When and from what source did the bank notes come into possession?
17. If any of the notes tendered represent borrowings, the name(s) and address(es) of the persons from whom borrowed and the dated on which borrowed.
18. Manner in which payment of value of the bank notes is desire; i.e., in cash or payment to bank, etc.
19. If payment is to be made into a bank account, full details of the bank account.
20. Has any other declaration been made in respect of other bank notes of the owner? If so, state full particulars.
21. If the declarant is not the owner of the bank notes, capacity in which declaration is signed.
I_________________, (name in block letters) son/daughter/wife of ________________ (name of father/husband) hereby solemnly declare that the particulars furnished above are full, true and correct to the best of my knowledge and belief, I further declare that the bank notes tendered herewith belong to me ___________ to__________ and are not held benami.
name of owner of bank notes not filed any other declaration under this I also solemnly affirm that I have _______________ filed another/other declaration(s) as per Act.
______________
particulars attached.
I further declare that I Amendment of section making this declaration in my capacity as ___________ and that I Amendment of section competent to make this declaration and verify it, designation, etc.
Place: ____________
Date: ____________
(Signature of declarant)
___________________________________________________________________
I, __________ (name in block letters) hereby testify that I know the declarant and certify that the above declaration was signed in my presence.
Place: ______________
Date: ______________
(Signature and designation)
 SEAL