Date: 24th October 2012

From: Name of the Assessee Address of the Assessee PAN: of the Assessee To: The ITO, Address. Sir, Ref: Your letter for Unpaid SA Tax for A.Y. 20XX-XX. Communication Reference No.: No.ABC/PQRS/S.A.Tax/NP/20XX-XX/123 dated 24th October 2012. Sub: Payment of Self Assessment Tax for AY 20XX-XX. With reference to the above I may state as under: I am in receipt of your above referred letter of communication, whereby I am required to pay self assessment tax amount of Rs. XX,XXX as per the return filed for AY 20XX-XX. In this regard I wish to state that I have paid an amount of RsXX,XXX on(Date of payment ) towards the self assessment tax liability for A.Y20XX-XX. The detail of enclosed challan is tabulated hereunder: Assessment Year 20XX-XX Particulars Self Assessment Tax Challan Amount (Rs.) XX,XXX Bank Detail ABCD Bank BSR Code XXXXXX Challan Sr. No. XXXXX

Kindly take the above on your records and oblige. Thanking you, Yours faithfully,

Name of the Assessee PAN: of the Assessee Enclosed please find; 1) Copy of S. A. Tax paid challan for AY 20XX-XX.