FORM G
Certificate quantifying amount of income-tax on withdrawal consequent upon closure of account
[See paragraph 12(2)]

Office of the Commissioner of Income-tax
Deposit Account No.             
Name of depositor                 
Permanent Account No.         
The depositor abovenamed wishes to close his Deposit Account No. I hereby certify that out of his share of the balance lying to the credit of his account, an amount of Rs. is payable by way of income-tax and the same should, therefore, be deposited by the deposit office before the balance left is transferred to the depositor's designated account.
Date :
Signed
Seal:                                                                                                 Designation of Assessing Officer