FORM NO. 142 [See Rule 219 - Statement of deduction or collection of tax at source under section 397(3)(b)] Quarterly statement of tax deposited in relation to transfer of virtual digital asset under section 393(1) [ Table: S. No. 8(vi)] to be furnished by an Exchange for the quarter ending ……. June/September/December/March of Tax Year
| Row No. | Part A: Particulars of the Exchange | ||
|---|---|---|---|
| 1. | Name | (refer Note 1) | |
| 2. | Address | (refer Note 2) | |
| 3. | Permanent Account Number | ||
| 4. | Email id | ||
| 5. | Contact number | Country Code | Number |
| 6. | Tax year |
| Part B: Details of transactions | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| (i) Details of tax paid with respect of transactions referred to in Rule 219 - Statement of deduction or collection of tax at source under section 397(3)(b): | |||||||||||||||||||||||
| Sl. No. | Na me of buy er/ brok er | Addr ess of buye r/ brok er | Perma nent Accou nt Numb er of buyer / broker | Nam e of the virtu al digit al asset (VD A) | Date of transa ction | Val ue of VD A bou ght by buy er/ brok er | Nu mb er of VD A bou ght by buye r/ brok er | Total consider ation | 1% of total consider ation | Date of tax paym ent | Challan details | ||||||||||||
| BS R cod e of ban k bra nch | Amo unt paid | Cha llan seri al nu mb er | |||||||||||||||||||||
| (A) | (B) | (C) | (D) | (E) | (F) | (G) | (H) | (I)=(G)* (H) | (J) | (K) | (L) | (M) | (N) | ||||||||||
| 1 . | |||||||||||||||||||||||
| 2 . | |||||||||||||||||||||||
| (ii) Details of transactions on which tax was not deducted in accordance with the guidelines issued under Section 400 - Power of Central Government to Relax Provisions of This Chapter section 400(2) | |||||||||||||||||||||||
| S l. No | Nam e of brok er | Addr ess of broke r | Permane nt Account Number of broker | Tax Deduction and Collection Account Number of broker | Name of the virtual digital asset (VDA) | Date of transaction | Value of VDA bought by buyer | Number of VDA bought by buyer | Total consider ation paid/ credited | ||||||||||||||
| (A) | (B) | (C) | (D) | (E) | (F) | (G) | (H) | (I) | (J)=(H)* (I) |
| 1. | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2. |
DECLARATION
I ………… (name of the person responsible for deducting tax at source) having Permanent Account Number
………… in my capacity as …… (designation) of ……. (name of the exchange) declare that to the best of my
knowledge and belief, the information furnished in the application is correct and truly stated.
Place: Signature of the person responsible for deducting tax at source Date: Name: Designation:
Notes:
- In case of individual, the first, middle and last name shall be provided in full without any abbreviations. In any other case also, name shall be provided in full.
- The address shall contain i. Country/Region, ii. Flat/Door/Block number iii. Road/Street/Block/Sector, iv. PIN/ZIP Code, v. Post Office, vi. Area/locality, vii. District, viii. State.
- Amounts to be filled in ₹ unless otherwise provided.