Finance PLC (PQ 526) No. 310, Galle Road, Colombo-03, Sri Lanka.

Tel: 2370990 Fax: 2375851 E-mail: info@vallibelfinance.com

vallibel

Financevallibel

Certificate No:

Branch

je,sn,a *skEkaia$ ntypgy; gpNdd;];$ Vallibel Finance

nÿ m%ldYk$ mwptpg;G tup >y $Declaration

TõMk;

Yes

ke;>y;iy

No

nÿ wkqmd;htup tpfpjhrhuk;

Tax Rate

Hold

Cheque to bank Bank slip

Special Approved :...........................................

Vallibel Finance PLC.

Finance (PQ 526)vallibel

No. 310, Galle Road, Colombo-03, Sri Lanka.

Tel: 2370990 Fax: 2375851

E-mail: info@vallibelfinance.com

1 Name With Initials (1 Depositor)

2 Name With Initials (2 Depositor)

3 Name With Initials (3 Depositor)

4 Name With Initials (Nominee)

5 Name With Initials (Correspondance)

6 Name With Initials (Payee)

Previous Deposit Certificate Declaration Receipt No:

Receipt Copy Cheque No: & Amount

KYC Form Realization Date

NIC/BR Copy

Billing

Allocated By Cheque Realization Confirmed By

Input By Activated By

Verified By Manager’s Signature(Approved)

BSP Code

BSP Code

BSP Code

BSP Code

BSP Code

BSP Code

............................................. .............................................

............................................. .............................................

............................................. .............................................

Account Operating Instructions

Anyone of Us* Withdrawal Either or Survivor Without Reference to Nominee/s

All Signatories Renewal

Vallibel Finance PLC

*Applies only for withdrawal at maturity & payment of interest/

Financevallibel

DEPARTMENT OF' INLA}{D REVENUE

To: Vallibel Finance PLC

No.310,

Galle Road,

Colombo 03.

Account No'.: .........

Year of Assessment:

DECLARATION (BY SENIOR CITIZENS)

hereby declare that;

I am a citizenand resident of Sri Lanka and asenior cilizen(as per the provisions of the Inland Revenue

Act, No. 24 of 2017) and,

1. The aggregate interest receivable by me for the above year of assessment on the monies deposited

in this account or any other account of this financial institution or any other accounts in any otherbank or any other financial institution does not exceed Rs. 1,500,000/:. Therefore, please refrainfrom deducting withholding tax on the interest payable on this account.

2.T1te aggregate of the interest receivable by me for the above year of assessment on the monies

deposited in this account or any other account of this financial institution or any other accounts inany other bank or any other financial institution rnay exceed the tax relief of Rs. 1,500,000/:.Therefore, please withhold tax on any interest in excess of Rs ........ which is thebalance ofthe tax relief.

@alance of the tax relief = Rs. 115001000/= - interest due up-to-date from all accounts otherthan this account for the above year of assessment)

3. The tax relief on interest income of Rs. 1,500,000i: which is available to senior citizen has been

availed by me in respect of the interest recsivable by me on the monies deposited in the otheraccounts of this financial institution or other banks or other financial institutions. Therefore, please

withhold tax on the total interest receivable by me from this account.

I certiff that the above declaration made by me is true and correct:

Any changes to my r?sidence status witl be notified to thefinancial institurion at the time of sueh change.

Date

(*pleas e s trike-off the s tatem ents not t rel evant)

Signature of the Declarant

I,....................

se6co qloco@ @eerbtlo@deo

OrBAC SarzzrJad 8.dC.A

o2rc.310,

ocg ecd,

ofsce@ 03 oOoo8.

6q1O qoroo ,

odedda Ob@co ,

erDr@eDco (od6do e6o6Bcod EBd IEOE @O€D)

(e3@gb6 nr@)

(88arce) E

eQ.8 oo8a3 groco zod 806.

@@ @ g"zscoO ocSro g{cogcs4 eeo od)sdc5 gdolSocod@. (2017 qors 24 q6a oQEa qcqcc:@ ers:or:} EOEocar

g2$cdO)

1. gero orzsloa46l Obeoce eeqaoc o@@ Eqgo@ ooC o@@ 9el EccaoaocJ oOar o@ 6gOzo otoC co@ oOarr:J

O1o4oal oroC ooz::r:J Qgr:cc,:o:::cazs olzdor$ s>d ErA pqd esqoc @c EBzsS gOa oec@ ozoqo

d1.1,500,000/= oo:c9d@ozrJoa3o:. OOIEaJ o@@ EEg@O oco6o: ga2 oec@ocsa3 dqOc ol8o@

Ag qQESo@aJ OgEo: o@:s3 zoc616arO g6fg@.

2. o@@ pgr qcceoz::ocd oor5rzrJ E€@E5J aso <e@ oOarrJ a1.4o6a3 ooC Qgr qcooz::cssaj E€@OEnJ

erAo: gA oec@oc3 OzsleO a:e, geon esqozsl E€oOriJ Oc 68aJ gEcoala:c oec$ qcqccso@ SzoqO ga::lr:doa461 Obec.: oqroc d1. 1,500,000/= ro pd oec@<sd gd@Eca o1zo. dOlEerJ, zodl<6czod oec@cs

61........ ..........................25J @rl dqOr olEo@ Og gQ n6aJa.

(Og tooaroxJ odoco - ft. 1,500,000/- - e.orr €oqEoerJ rodod6. Oboo toqoc oOO 6€0 !'6d qEril 8od@E€ooehrJ EoOa Qeao ooc@o)

odledd gdOl8caa} e,:qarc qrE dr. 1,500,000/= zo oec@ qrqc<,:@ Og ee?rrr"rca o@@ 9er5 Ec<,:olr:lo.cJ oors:6J

cs@ Eg@Og oeoi oO:::r:J Ol"qOzo oatC oOa:r:J persc<.:oa:csr:: zl1a3oa2 $q6f grsr @c 38zrJ gOc oaJarc

oec@ qcqccs@ @c EBarJ gOcooa q1o. O01Ea3, o@O EEio.O:rJ @c gOcoafa:c $d ooc@c,: eeqeoc

zod16cto6 dqOcolEo@ Ag qQzsrdafu:.

dc8ro qgg0od qoroo, O6oooolo:c ogolcolEo@ qorso t-

9o5a3 eqeo:d tsl€ gzs3(oo5 rarrD erc EO16Q Aoo @@ rsa;Ezsl oo@.

Oc oQo6 dd*oooj cs0 eOomd $Ooocd d qdOroOQ d aO ger qccor$2rrc,3 o0ro Qrr}oc AAO.

Qoro

(* zodl.dczod Eqce o.arco2rr Oczors zslocq@aJa: )

gacoroed qdtora