Annexure -A (Certificate to be used by a Member of Parliament/Member of Legislative Assembly / Municipal Councillor or Gazetted Officer under sub-rule (4) of rule 114 of the Income-tax Rules, 1962)
You can download the format using below link from NSDL website:
https://www.tin-nsdl.com/download/Format-of-Gazette-Certificate_03082012.pdf