FORM NO. 22
[See rule 33]
Statement of tax deducted at source from contributions repaid to employees in the case of an approved superannuation fund

1. Name of the superannuation fund                                                        
2. Name and address of the employee                                                    
3. The period for which the employee has contributed to the superannuation fund          
4. The amount of contributions repaid-
(a) principal                                                                                 
(b) interest                                                                                   
5. The average rate of deduction of tax during the preceding three years  
6. Amount of tax deducted on repayment                                                
We, the trustees of , do hereby declare that the above particulars are correct.
Date:                                                                                                     
Signature