Form 216A

(See sub-rule (3BB) of rule 19)

Statement for claiming the credit for the amount deducted as tax in accordance with the provisions of section 59B of the Act

Period from ………………… to ………………

Name of the dealer ………………………………………………………….

Address ………………………………………………………………………

* A separate sheet is to be attached for more details.

I solemnly declare that the above statements are true to the best of my knowledge and belief.