FORM DA
[See rule 4A and 4AA]
Form of application for settlement of cases under section 22C(1) of Wealth-tax Act, 1957

IN THE SETTLEMENT COMMISSION ....................... *Settlement Application No. ....... 19...... 19.......

1.	Full name and address of the applicant		
2.	Permanent Account Number 		
3.	Status [See Note 4]		
4.	The Commissioner having jurisdiction over the applicant		
5.	Assessment  year(s) in connection with which the application for settlement is made		
6.	Date of filling the return(s) of wealth for assessment year(s) referred to in column 5		
7.	Proceedings to which application for settlement relates, the date from which proceedings are pending and the wealth-tax authority before whom the proceedings are pending [See note 6]		
8.	Where any appeal or application for revision has been preferred after the expiry of the period specified for the filing of such appeal or application for revision, as the case may be, whether such appeal or  revision has been admitted 		
9.	Date of seizure, if any, under section 37A of the Wealth-tax Act		
10.	Particulars of the issues to be settled, nature and circumstances of the case and complexities of investigation involved [See Note 7]		
11.	Full and true disclosure of wealth which has not been disclosed before the Assessing Officer, the manner in which such wealth has been derived and the additional amount of Wealth-tax payable on such wealth [See notes 9 and 10]		
	.................................................
Signed
(Applicant)	

Verification
I, .........................................................................................................................................................................
Son/daughter/wife of ............................ do hereby solemnly declare that to the best of my knowledge and belief, what is stated above and in the Annexure [including the statement(s) and documents accompanying such Annexure is correct and complete. I further declare that I am making this application in my capacity as ............................................................................................................... and that I am competent to make this 
		(designation)
application and to verify it. 
Verified today the ........................................... day of ........................... 19 ...............

Notes :
1.	The application for settlement must be in quintuplicate.
2.	The application for settlement must be accompanied by a fee of five hundred rupees. The fees should be credited in a branch of the authorised bank or branch of the Reserve Bank of India and the triplicate Challan sent to the Settlement Commission with the application for the settlement. The Settlement Commission will not accept cheques, drafts, hundies or other negotiable instruments.
3.	*The number and year of application will be filled in the office of the Settlement Commission.
4.	Please state whether individual, Hindu undivided family, or a company.
5.	If the space provided is found insufficient, separate enclosures may be used for the purpose.
6.	In case of assessment proceedings, indicate the designation of the Assessing Officer Deputy Commissioner before whom the proceedings are pending indicating also the date of services of notice under section 14(2)/section 17 of the Wealth tax Act, 1957, or, as  the case of appellate proceeding, indicate the appellate authority before whom the appeal is filed and the date of filling of the appeal. In case of revision petition, indicate the date of filling the revision petition and whether the same is filed within time or not.
7.	 Full details of issues for which application for settlement is made, the nature and circumstances of the case and complexities of the investigation involved must be indicated against item 10. Where the application relates to more than the one assessment year, these details should be furnished for each assessment year.
8.	The application amount for settlement of a case shall not be allowed to be withdrawn by the applicant.
9.	The additional amount of wealth-tax payable on the wealth referred to in item 11 should be calculated in the manner laid down in sub-section (1A) to (1D) of section 22C.
10.	The details reffered to in item 11 shall be given in the Annexure to this application.

ANNEXURE
1.	Statement which has not been disclosed before the 
2.	[Assessing Officer ]		
3.	Additional amount of wealth-tax payable on the said wealth		
4.	Full and true statement of the facts regarding issues to be settled, including the terms of settlement sought for by the applicant 		
5.	The manner in which the wealth referred to in item No. 1 has been derived.		
		
Place ..................	................................	
Date ...................	Signed
(Applicant)	

Note : The Annexure should be accompained by ___
(1)	A statement(s) containing computation of net wealth of the applicant for the assessment year or years to which the application for settlement relates, in accordance with the provisions of the Act; and
(2)	A detailed statement of assets (moveable and immovable) and debts, located in India and outside, as on the valuation date