This document is an income tax challan form used to make various income tax payments in India. It contains fields to enter details of the taxpayer like permanent account number, name, address and contact details. It also contains fields to specify the type of tax payment like advance tax, self-assessment tax, tax on distributed profits etc. and the amount being paid. Notes on the reverse provide instructions on using separate challans for different payments, quoting permanent account number, depositing appeal fees and taxes for block periods. It also mentions the bank acknowledgement should contain the 7 digit BSR code, deposit date and challan serial number to be quoted in the income tax return.