FORM NO 13D
[See rule 28(4)]
Application for a certificate under section 194G(2) of the Income-tax Act, 1961, relating to deduction of income-tax from payments of commission, etc., made to persons who are or have been stocking, distributing, purchasing or selling lottery tickets

To
The Assessing Officer,
……………………….
Sir,
I,…………………[name], of……………………..[address] do hereby declare that my total income (including income comprised in payments of the nature referred to in section 194G of the Income-tax Act, 1961) computed in accordance with the provisions of that Act for the previous year relevant to the assessment year…………………………*was less than the minimum liable to income-tax/amounted to Rs……………..and I have no  reason to expect that my total income (computed as aforesaid) for the three assessment years next following will increase substantially.
2. I, therefore, request that a certificate may be issued to the person(s) responsible for paying income by way of commission, remuneration or prize (by whatever name called) on the sale of lottery tickets, particulars of which are given in the Schedule hereto, authorising him/them  *not to deduct income-tax/to deduct income-tax at the rate of…………….per cent at the time of credit of such income to my account or, as the case may be, payment thereof to me.
3. I hereby declare that what is stated in this application is correct.
Signature
Date                            
Address
Permanent Account Number
SCHEDULE

SI. No.	Name and address of person(s) responsible for paying commission, remuneration or prize (by whatever name called) on the sale of lottery tickets	Amount of  * commission / remuneration / prize

Date………………                                                                                                         …………..
     Signature
*Score out whichever is not applicable.