Form No. 22
[See rule 33]
Statement of tax deducted at source from
contributions repaid to employees in
the case of an approved superannuation fond
| 1. | Name of the superannuation fund | |
| 2. | Name and address of the employee | |
| 3. | The period for which the employee has contributed to the superannuation fund | |
| 4. | The amount of contributions repaid -- | |
| (a) principal | ||
| (b) interest | ||
| 5. | The average rate of deduction of tax during the preceding three years | |
| 6. | Amount of tax deducted on repayment |
| We, the
trustees of ________________ are correct . |
,do hereby declare that the above particulars |
| Date: | Signature |