FORM NO.

15H
[See Section 197A(1C) and Rule 29C(1A)]
Declaration under section 197A(1C) of the Income Tax Act, 1961 to be made by an indiidual !ho is of the a"e of sixty #ear or more claimin" certain recei$ts !ithout deduction of
tax%
&art ' I
()% Details of Inbestment in res$ect of !hich the Declaration is bein" made*
+chedule I
(Details of +hares, !hich stand in the name of the declarant and beneficially o!ned by him)
,o% of +hares Class of +hares - .ace /alue of
0ach +hares
Total /alue of +hare Distinctie ,o of +hares Date(s) on !hich the shares !ere ac1uired by the
declarant (dd2mm2yyyy)
+chedule II
(Details of +ecurities held in the name of the declarant and beneficially o!ned by him)
Descri$tion of
+ecurities
,o% of +ecurities Amount of +ecurities Date(s) of +ecurities
(dd2mm2yyyy)
Date(s) on !hich the securities !ere ac1uired by the
declarant (dd2mm2yyyy)
+chedule III
(Details of sum "ien by the declarant on interest)
,ame - Address of the $erson to !hom the sums are "ien
on interest
Amount of +um "ien
on interest
Date on !hich the sum !as "ien
on interest (dd2mm2yyyy)
&eriod for !hich such sum
!ere "ien on interest
3ate of Interest
+chedule I/
(Details of 4utual .und 5nits held in the name of the declarant and beneficially o!ned by him)
,ame - Address of the 4utual .und ,o% of 5nits Class of 5nit and .ace alue of
each unit
Distinctie no% of 5nits Income in
res$ect of units
+chedule /
(Details of !ithdra!al made from ,ational +ain"s +ceme)
&articulars of &ost 6ffice !here the account under the ,ational +ain"s scheme is maintained and Account ,o% Date on !hich the account
!as o$ened (dd2mm2yyyy)
The amount of !ithdra!al
from account
+i"nature of the Declarant
Declaration2 /erification
1% ,ame of Assessee (Declarant)* (% &A, of Assessee *
)% A"e * 7% Assessment #ear *
(.or !hich declaration is bein" made)
8% .lat2 Door2 9loc: ,o%* 6% ,ame of &remises* 7% Assessed in !hich ;ard 2 Circle *
<% 3oad2 +treet2 =ane* 9% Area2 =ocality* 1>% A6 Code*
( 5nder !hom assessed last time)
Area Code A6 Ty$e 3an"e Code A6 ,o%
11% To!n2 City2 District*
1(% +tate*
1)% &I,* 17% =ast Assessment year in !hich assessed*
18% 0mail 16% Tele$hone ,o% (!ith +TD code) and
4obile ,o%*
17% &resent ;ard2 Circle
1<% ,ame of 9usiness2 6ccu$ation * 19% &resent A6 Code ( if not same as aboe)
(>% ?urisdictional Chief Commissioner of Income tax or Commissioner of Income Tax ( if not
assessed to Income Tax earlier*
Area Code A6 Ty$e 3an"e Code A6 ,o%
(1% 0stimated Total Income from the sources mentioned belo!
) &lease Tic: the 3eleant 9ox (
Diidend from +hares referred to in +chedule I
Interest on +ecurities referred to in schedule II
Interest on sums referred to in schedule III
Income from 5nits referred to in schedule I/
The amount of !ithdra!al referred to in Clause (a) of +ub ' section ( of +ection <>CCA referred to in schedule /
((% 0stimated total income of the $reious year in !hich income mentioned in column (1 to be included
I @@@@@@@@@@@@@@@@@ do hereby declare that I am resident in India !ithin the meanin" of section 6 of the Income Tax Act, 1961% I also,
hereby declare that to the best of my :no!led"e and belief !hat is stated aboe is correct, com$lete and is truly stated and the incomes
referred to in this form are not includible in the total income of any other $erson u2s 6> to 67 of the Income Tax Act, 1961% I further, declare
that the tax on my estimated total income, includin" Aincome2 incomes referred to in column (1 com$uted in accordance !ith the $roisions
of the Income Tax Act, 1961, for a $reious year endin" on )1
st
4arch BBBBBBB releant to the Assessment
yearBBBBBBBB !ill be nil%
&lace*
Date*
+i"nature of the Declarant
&A3T II
C.or use by the $erson to !hom the declaration is furnishedD
1% ,ame of the $erson res$onsible for $ayin" the income referred to in column (1 of &art I* (% &A, of the $erson indicated in column 1 of
&art II*
)% Com$lete Address* 7% TA, of the $erson indicated in column 1 of
&art II*
8% 0mail 6% Tele$hone ,o% (!ith +TD code) and 4obile
,o%*
7% +tatus*
<% Date on !hich declaration is furnished
(dd2mm2yyyy)
9% &eriod in res$ect of !hich the diidend has
been declared or the income has been $aid2
credited*
1>% Amount of Income
&aid*
11% Date on !hich the
income has been $aid2
Credited
(dd2mm2yyyy)
1(% Date of declaration, distribution or $ayment of diidend 2 !ithdra!al under
the ,ational +ain"s +cheme
(dd2mm2yyyy)
1)% Account no% of ,ational +ain"s +cheme from !hich !ithdra!al has
been made*
.or!arded to Chief Commissioner or Commissioner of Income TaxBBBBBBBBBBBBBBBBBBB%%
&lace*
Date*
+i"nature of the $erson res$onsible for $ayin" the
income referred to in column (1 of &art I
,otes*
1% The declaration should be furnished in du$licate%
(% A Delete !hicheer is not a$$licable%
)% 9efore si"nin" the erification, the declarant should satisfy himself that the information furnished in the declaration is true, correct and com$lete in all res$ects%
Any $erson ma:in" a false statement in the declaration shall be liable to $rosecution under section (77 of the Income Tax Act, 1961 and on coniction be $unishable '
(i) In a case !here tax sou"ht to be eaded exceeds t!enty fie la:h ru$ees, !ith ri"orous im$risonment !ich shall not be less than six months but
!hich may extend to seen years and !ith fine E
(ii) In any other case, !ith ri"orous im$risonment !hich shall not be less than three months but !hich may extend to t!o years and !ith fine%
7% The $erson res$onsible for $ayin" the income referred to in column (1 of &art I shall not acce$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 li:ely to be credited or $aid durin" the $reious year in !hich such income is to be
included exceeds the maximum amount !hich is not char"eable to tax and deduction(s) under Cha$ter /I A, if any , for !hich the declarant is eli"ible%