Declaration by the Insurance Company for non-deduction of tax at source u/s. 194 of the Act. 
(On the letterhead of the Insurance Company) 
  
I, _____________________________________________________________; in the capacity of ______________ of ________________________ (Specify name of the insurer), having registered office at _______________________ and PAN as ________________ (copy attached); hereby declare that: 
 
a. _________________________________ (Specify name of the Insurer) is a corporation covered under the provisions of section 194 of the Act or is an “insurer” as defined in section 2(28BB) of the Act. 
 
b. It is further declared that the said corporation has full beneficial interest in respect of shares issued and allotted by M/s. Unichem Laboratories Limited. (the Company) bearing Folio No. ___ to ___ vis-à-vis dividend distributed or paid during the year ending on 31st March, 2023 in respect of said shares even though said shares are owned by _________________ (Specify name and address of the Shareholder), having PAN as ________________ (copy attached) 
  
c. Accordingly, it is further declared that provisions of section 194 of the Act regarding deduction of tax at source in respect of dividend on said shares are not applicable to dividend distributed or paid by the Company during the year ending on 31st March, 2023. 
  
d. In view of the same, it is requested that no deduction of tax u/s. 194 be made in respect of dividend distributed or paid by the Company during the year ending on 31st March, 2023 on the said shares.  
 
Verification 
I. . . . . . . . . . . . . . . . . . . do hereby declare that to the best of my knowledge and belief what is stated above is correct complete and is truly stated.  
Verified today the . . . . . . . . . . . . . . . . . . . day of. . . . . . . . . . . . .   
 
Name and Signature of the person for on behest of the corporation 

Name and Signature of the person for on behest of the shareholder 
Place: . . . . . . . . . . . . . . . . . . .   
 
Encl: As above