FORM NO.

27A
Form for furnishing information with the return or statement of deduction of tax at source filed on
computer media for the period
(From 01/01/2010 To 31/03/2010)

1 (a) Tax Deduction CALS11911E (d) Financial Year 2009-2010

Account No.
(b) Permanent AAICS0242D (e) Assessment Year 2010-2011
Account No.
(c) Form No. 24Q (f) Previous receipt
number

2 Particulars of the deductor 3 Name of the person responsible for deduction

of tax
(a) Name SRI BALMUKUND POLY (a) Name AJAY KUMAR
PLAST PVT LTD AGRAWAL
(b) Type of deductor Company (b) Address
(c) Branch/Division Flat No. 32
(d) Address Name of the OM TOWER
premises/building
Flat No. 32 Road / Street / CHAURANGI ROAD
Lane
Name of the OM TOWER Area / Location CHAURANGI ROAD
premises/building
Road / Street / CHAURANGI ROAD Town / City / KOLKATA
Lane District
Area / Location CHAURANGI ROAD State WEST BENGAL
Town / City / KOLKATA Pin Code 700071
District
State WEST BENGAL Telephone No.
Pin Code 700071 E-mail
Telephone No.
E-mail

4 Control Totals
Sr. No. No. of Deductee Amount Paid Tax Deducted Tax Deposited
Records
Total 2 1140000 148481 148481

5 Total Number of Annexures enclosed

6 Other Information

Verification
I, AJAY KUMAR AGRAWAL, certify that all the particulars furnished above are correct and complete.

Place : KOLKATA Signature of person responsible for deducting tax at source

Date : 26/06/2010 Name and designation of person responsible for deducting
tax at source AJAY KUMAR AGRAWAL (DIRECTOR)

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