7.

AssessedinwhichWard/Circle

No.of
shares
Totalvalue
ofshares
Amountof
securities
Amountof
sumsgiven
oninterest
Rateof
interest
Numberof
units
(DetailsofthewithdrawalmadefromNationalSavingsScheme)
RangeCode
8.Road/Street/Lane
13.PIN
InterestonsumsreferredtoinScheduleIII
9.Area/Locality
14.LastAssessmentYearinwhichassessed
17.PresentWard/Circle
12.State
3.Age 4.AssessmentYear
(forwhichdeclarationisbeingmade)
1.NameofAssessee(Declarant)
10.AOCode(underwhomassessedlast
time)
AreaCode
AONo.
19.PresentAOCode(ifnotsameasabove)
AOType
"FORMNO.15H
[Seesection197A(1C)andrule29C(1A)]
PARTI
Declarationundersection197A(1C)oftheIncometaxAct,1961tobemadebyanindividualwhoisoftheageofsixtyyearsormoreclaimingcertainreceipts
withoutdeductionoftax.
5.Flat/Door/BlockNo. 6.NameofPremises
2.PANoftheAssessee
18.NameofBusiness/Occupation
15.Email 16.TelephoneNo.(withSTDCode)andMobileNo.
20.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessed
toIncometaxearlier)
11.Town/City/District
RangeCode AONo.
IncomefromunitsreferredtoinScheduleIV
AOType
AreaCode
21.Estimatedtotalincomefromthesourcesmentionedbelow
DividendfromsharesreferredtoinScheduleI
InterestonsecuritiesreferredtoinScheduleII
(Pleaseticktherelevantbox)
SCHEDULEV
Nameandaddressofthe
persontowhomthesumsare
givenoninterest
SCHEDULEII
ParticularsofthePostOfficewheretheaccountundertheNational
SavingsSchemeismaintainedandtheaccountnumber
Dateonwhichtheaccountwas
opened(dd/mm/yyyy)
Theamountof
withdrawalfromthe
account
Nameandaddressofthe
mutualfund
SCHEDULEIII
(Detailsofthesumsgivenbythedeclarantoninterest)
SCHEDULEIV
(Detailsofthemutualfundunitsheldinthenameofdeclarantandbeneficiallyownedbyhim)
Theamountofwithdrawalreferredtoinclause(a)ofsubsection2ofsection80CCAreferredtoinScheduleV
22.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn21istobeincluded
(Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim)
23.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade:
Numberofsecurities
Descriptionof
securities
SCHEDULEI
Date(s)of
securities
(dd/mm/yyyy)
Date(s)onwhichthesecuritieswereacquiredbythe
declarant(dd/mm/yyyy)
Classofshares&
facevalueofeach
share
Distinctivenumbersof
theshares
Date(s)onwhichtheshareswereacquiredbythe
declarant(dd/mm/yyyy)

Classofunitsandface
valueofeachunit
Distinctivenumberofunits
Incomeinrespectof
units
Periodforwhichsuchsumswere
givenoninterest
Dateonwhichthesumswere
givenoninterest(dd/mm/yyyy)
(Detailsofthesecuritiesheldinthenameofdeclarantandbeneficiallyownedbyhim)
Place:
Date:
Place:
Date:
Notes:
1.
2.
3.
i)
ii)
4.
Before signing the verification , the declarant should satisfy himself that the information furnished in the declaration is true, correct and complete in all
respects. Any person making a false statementin the declaration shall be liable to prosecution under 277 of the Incometax Act, 1961 and on conviction be
punishable
[Forusebythepersontowhomthedeclarationisfurnished]
*Deletewhicheverisnotapplicable.
The person responsible for paying the income referred to in column 21 of Part I shall not accept the declaration where the amount of income of the nature
referred to in section 197A(1C) or the aggregate of the amounts of such income credited or paid or likely to be credited or paid during the previous year in
which such income is to be included exceeds the maximum amount which is not chargeable to tax and deduction(s) under Chapter VIA, if any, for which the
declarantiseligible.";
In a case where tax sought to be evaded exceeds twentyfive lakh rupees, with rigorous imprisonment which shall not be less than 6 months but
whichmayextendtosevenyearsandwithfine;
Inanyothercase,withrigorousimprisonmentwhichshallnotbelessthan3monthsbutwhichmayextendtotwoyearsandwithfine.
PARTII
2.PANofthepersonindicatedinColumn1ofPartII
4.TANofthepersonindicatedinColumn1ofPartII
ForwardedtotheChiefCommissionerorCommissionerofIncometax
..
5.Email
Thedeclarationshouldbefurnishedinduplicate.
6.TelephoneNo.(withSTDCode)andMobileNo.
7.Status
Declaration/Verification
SignatureoftheDeclarant
..
..
.
Signature of the person responsible for
paying the income referred to in Column
21ofPartI
.
.
3.CompleteAddress
I.do hereby declare that I am resident in India within the meaning of section 6 of the Incometax Act, 1961. I also, hereby declare that to
the best of my knowledge and belief what is stated above is correct, complete and is truly stated and that the incomes referred to in this form are not
includible in the total income of any other person u/s 60 to 64 of the Incometax Act, 1961. I further, declare that the tax on my estimated total income,
including *income/incomes referred to in column 21 computed in accordance with the provisions of the Incometax Act, 1961, for the previous year ending on
....................relevanttotheassessmentyear..................willbenil.
.
SignatureoftheDeclarant
12.Dateofdeclaration,distributionorpaymentof
dividend/withdrawalundertheNationalSavings
Scheme(dd/mm/yyyy)
13.AccountnumberofNationalSavingsSchemefromwhichwithdrawalhasbeenmade
8.Dateonwhichdeclarationisfurnished
(dd/mm/yyyy)
9.Periodinrespectofwhichthedividendhasbeen
declaredortheincomehasbeenpaid/credited
10.Amountofincomepaid 11.Dateonwhichthe
incomehasbeenpaid/
credited(dd/mm/yyyy)
1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn21ofPartI