FORM NO.

15H
[See section 197A(1C), 197A(1A) and rule 29C(1A)] Declaration under section 197A(1C) of the Incometax Act, 19 1 to !e made !" an indi#idual $ho is of the a%e of sixt" "ears or more claimin% certain recei&ts $ithout deduction of tax' PART - I 1] (ame of Assessee (Declareant) ) 2] *A( ) +] A%e ) ,] Assessment -ear 7] Assessed in $hich 3ard 0 Circle 17] A8 Code ($hom assessed last time) ) Area 5an%e A8 9"&e Code Code 1,] 6ast Assessment -ear in $hich assessed ) 17] *resent 3ard 0 Circle 19] *resent A8 Code (if not same as a!o#e)) Area Code A8 9"&e 5an%e Code A8 (o'

.] /lat 0 Door 0 1loc2 (o' ) 4] 5oad 0 Street 0 6ane )

] (ame of *remises ) 9] Area 0 6ocalit" )

A8 (o'

11] 9o$n 0 Cit" 0 District )

12] State ) 1+] *I( 1 ] 9ele&hone 0 ;o!ile (o )

1.] :mail ) 14] (ame of 1usiness 0 8ccu&ation )

27] <urisdictional Chief Comm' of Income 9ax or Comm' of Income 9ax (if not assessed to income tax earlier)) 21] :stimated total income from the sources mentioned !elo$)

(*lease tic2 the rele#ant !ox)

Di#idend from shares referred to in Schedule = I Interest on securities referred to in Schedule = II Interest on sums referred to in Schedule = III Income form units referred to in Schedule = I> 9he amt of $ithdra$al referred in clause(a) of su!sec=2 of sec=47CCA referred in Schedule = > 22] :stimated total income of the &re#ious "ear in income mentioned in Col = 21 to !e included ) 2+] Details of in#estments in res&ect of $hich the declaration is !ein% made ) SCHEDULEI (Details of shares, $hich stand in the name of the declarant and !eneficiall" o$ned !" him) Class of shares ? face 9otal #alue Distincti#e num!ers Date on $hich the shares $ere ac@uired #alue of each share of shares of the shares !" the declarant (dd0mm0"""")

(o' of shares

Descri&tion of securities

SCHEDULEII (Details of the securities held in the name of declarant and !eneficiall" o$ned !" him) Date(s) of (um!er of Amount of Date(s) on $hich the securitues $ere securities securities securities ac@uired !" declarant (dd0mm0"""") (dd0mm0"""")

SCHEDULEIII (Details of the sums %i#en !" the declarant on interest) (ame and address of the &erson to $hom the sums are %i#en on interest Amount of sums %i#en on interest Date on $hich sums %i#en on Interest (dd0mm0"""") *eriod for $hich sums $ere %i#en on interest 5ate of interest

SCHEDULE IV (Details of the mutual fund units held in the name of declarant and !eneficiall" o$ned !" him) (ame and address of the Class of units ? face Distincti#e Income (um!er of units mutual fund #alue of each unit num!er of units in res&ect of units

SCHEDULEV (Details of the $ithdra$al made from (ational Sa#in%s Scheme)

*articulars of the *ost 8ffice $here the account under the (ational Sa#in%s Scheme is maintained and the account num!er

Date on $hich the account $as o&ened (dd0mm0"""")

9he amount of $ithdra$al from the account

Signature ! t"e De#$arant

De#$arati n % Veri!i#ati n
AI0 3e do here!" declare that I am resident in India $ithin the meanin% of section of the Incometax Act, 19 1' I also, here!" declare that to the !est of m" 2no$led%e and !elief $hat is stated a!o#e is correct, com&lete and is trul" stated and that the incomes referred to in this form are not includi!le in the total income of an" other &erson u0s 7 to , of the Incometax Act, 19 1' I further, declare that the tax m" estimated total income, includin% Aincome 0 incomes referred to in column 21com&uted in accordance $ith the &ro#isions of the Incometax Act, 19 1, for the &re#ious "ear endin% on &1.'&.('))) rele#ant to the rele#ant to the assessment "ear ('))) - ))) $ill !e nil'
*lace ) Date )
x

Signature ! t"e De#$arant

PART - II [/or use !" the &erson to $hom the declaration is furnished] 1] (ame of the &erson res&onsi!le for &a"in% the income referred to in Column 2] *A( of the &erson indicated in Column 1 of *art II 21 of *art I ) +] Com&lete Address ) ,] 9A( of the &erson indicated in Column 1 of *art II )

.] :mail )

] 9ele&hone 0 ;o!ile (o ) 9] *eriod in res&ect of $hich the di#idend has !een declared or the income has !een &aid 0 credited )

7] Status )
11] Date on $hich the income has !een &aid 0 credited (dd0mm0"""") )

4] Date on $hich Declaration is /urnished (dd0mm0"""") )

17] Amount of income &aid)

12] Date of declaration, distri!ution or &a"ment of di#idend0 $ithdra$al under the (ational Sa#in%s Scheme(dd0mm0"""") )

1+] Account (um!er of (ational Sa#in% Scheme from $hich $ithdra$al has !een made )

/or$arded to the Chief Commissioner or Commissioner of Incometax BBBBBBBBBBBBBBB

*lace ) Date )

Si%nature of the &erson res&onsi!le for &a"in% the income referred to in Column 21 of *art I

(otes) 1' 9he declaration should !e furnished in du&licate' 2' A Delete $hiche#er is not a&&lica!le' +' 1efore si%nin% the #erification, the declarant should satisf" himself that the information furnished in the declaration is true, correct and com&lete in all res&ects' An" &erson ma2in% a false statement in the declaration shall !e lia!le to &rosecution under section 277 of the Income 9ax Act, 19 1 and on con#iction !e &unisha!le C (i) In a case $here tax sou%ht to !e e#aded exceeds t$ent" fi#e la2h ru&ees, $ith ri%orous im&risonment $ich shall not !e less than six months !ut $hich ma" extend to se#en "ears and $ith fine D (ii) In an" other case, $ith ri%orous im&risonment $hich shall not !e less than three months !ut $hich ma" extend to t$o "ears and $ith fine' 9he &erson res&onsi!le for &a"in% the income referred to in column 21 of *art I shall not acce&t the declaration $here the amount of income of the nature referred to in section 197A(1C) or the a%%re%ate of the amounts of such income credited or &aid or li2el" to !e credited or &aid durin% the &re#ious "ear in $hich such income is to !e included exceeds the maximum amount $hich is not char%ea!le to tax and deduction(s) under Cha&ter >I A, if an" , for $hich the declarant is eli%i!le'