FORM NO.64
Statement of income distributed by Venture Capital Company or a Venture Capital Fund
to be furnished under section 115U of the Income-tax Act, 1961
1. Name of the Venture Capital Company or
Venture Capital Fund and the address of
registered office
2. Permanent Account Number
3. Previous Year ending
4. Name and address of the Directors of the
Venture Capital Company/trustees of the
Venture Capital Fund
5. Total income under all heads received from
the investments in Venture Capital
Undertakings (6+8+10+12)
6. Total income received from the
investments in Venture Capital
Undertakings under the head ‘Long term
Capital Gains’
7. Proportion of (6 to 5)
8. Total income received from the
investments in Venture Capital
Undertakings under the head ‘Short term
Capital Gains’
9. Proportion of (8 to 5)
10. Total Dividend income received from the
investments in Venture Capital
Undertakings
11. Proportion of (10 to 5)
12. Other income (such as interest etc.)
received from the investment in Venture
Capital Undertakings
13. Proportion of (12 to 5)

14. Details of persons receiving income from the Venture Capital Company or the Venture Capital Fund in
the following format:-
S. Name(s) Address(es) PAN Circle/ Total Amount Amount Amount Other
No.
 Ward/ amount paid paid paid as Income
Special paid under under ‘Dividend’ such as
Range ‘Long ‘Short
where Term Term
assessed Capital Capital
to Gains’ Gains’
Income- [Column [Column [Column [Column
tax 6 X 6 X 6 X 6 X
Sl.No.7] Sl.No.9] Sl.No.11] Sl.No.13]
1 2 3 4 5 6 7 8 9 10
Enclose a copy of the Certificate of Registration under the Securities and Exchange Board of India Act, 1992.
Enclose a copy of the Venture Capital Fund deed in case of Venture Capital Fund registered under the
provisions of the Registration Act, 1908.
Enclose audited account including balance sheet, annual report, if any, with certified copies of income and
appropriation towards distribution of income.
I ...................................................................... son/daughter/wife of .......................................................
(name in full and in block letters)
do hereby solemnly declare that to the best of my knowledge and belief what is stated above and in the
annexure(s), including the documents accompanying such annexure(s), is correct and complete. I further
declare that I am furnishing such statement in my capacity as .......................................................... and that
I am competent to furnish this statement and verify it.  (designation)
Verified today the ............................day of .......................
Place ...............................
 Signature .....................................
Date. ...............................
 Verification
I/We ...................................................................................................... have examined the books of
accounts and other documents showing the particulars of income earned and the income distributed to the
investors by the .................................................................................. for the previous year ending ..................
(name of the Venture company or the Venture capital fund)
2. I/We declare that the above particulars are true and correct to the best of my/our knowledge and belief.
Place ..............................
 (Signature with name of the accountant)
Date ...............................
Notes.-1. “Accountant” means the accountant as defined in the Explanation to sub-section (2) of section 288
of the Income tax Act, 1961.