FORM C
[See sub-paragraph (1) of paragraph 9]
[Name of the Deposit Office]
Serial No.

Application for withdrawal of amount from account-A under the Capital Gains Accounts Scheme, 1988

To
The Manager
[Name and address of the Deposit Office]
I, [Name of the Applicant/Depositor], son of residing at
[Address of the applicant/depositor] wish to withdraw a sum of Rs.[in figures] (Rupees)[in words] from the account-A No. (pass book No.) maintained
with your office, in my name/ the name of [Name & address of the depositor]
2. I hereby declare and confirm that the amount sought to be withdrawn is proposed to be utilised in terms of the provisions of section 54/ section 54B/ section 54D/ section 54F/ section 54G/ section 54GB of the Act for the following purposes.

(i)
3. I request you to please pay the aforesaid amount of withdrawal in the following manner:
(i) Amount of Rs. [in figures] (Rupees ) [in words] may be paid in cash for the
purposes mentioned at Serial No. of column 2 here in above;
(ii) Amount of Rs. [in figures] (Rupees ) [in words] may be paid to
[Name and address of the party to whom payment is to be made] by way of Pay Order/Demand Draft for the purposes mentioned at Serial No. of column 2 here in above.
4. The application is made by me as guardian on behalf of aforesaid depositor [Name of the depositor] who is a minor.
5. The application is made by me as authorised officer of the aforesaid depositor firm / company/ association of persons/body of individuals.
6.The application is made by me as karta of the aforesaid depositor Hindu undivided family.
Signature/Thumb impression of the Depositor/the
Guardian/Karta/Authorised Officer of the Depositor
Date :
Place : Additional specimen
FOR THE USE OF DEPOSIT OFFICE
(i) Withdrawal for total amount of Rs. allowed/ not allowed because the depositor has not furnished the requisite details in respect of his preceding withdrawal/not allowed in terms of the provision of sub-paragraph (4) of paragraph 9 as the withdrawal has been sought in cash.
(ii) Amount of withdrawal has been made as per below :
(a) Cash Rs.
(b) Cheque/Demand Draft issued [Details may be noted]
Date :
Officer-in-charge
FORM C
Notes:
1. Delete whatever is not applicable.
2. Please mention the details of purpose for which amount is sought to be withdrawn.
3. Please mention the details of amount sought to be paid in cash and by way of Pay Order/Demand Draft with reference to the specific purpose and serial number at which such purpose has been mentioned under column 2 of the application and also the name of the party, account number (if any) of the party in whose
favour Demand Draft/Pay Order is sought to be issued.
4. Columns 4, 5, 6 pertain to deposits made on behalf of a minor, a company, a firm, a Hindu undivided family, association of persons, body of individuals. Hence in case of individual deposit these columns may be scored out and in other cases one column which is applicable may be retained and the remaining two columns may be scored out.
5. Details pertaining to column No. 2/3 may be furnished by way of Annexure or Annexures if the space provided in the columns is not sufficient to furnish the details.