Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax
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1
2FORM 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 individual who is of the age of sixty years or
more claiming certain receipts without deduction of tax.
PART‐I
1. Name of Assessee (Declarant)
2. PAN of the Assessee
3. Age
4. Assessment Year
(for which declaration is being made)
5. Flat/Door/Block No.
6. Name of Premises
7. Assessed in which Ward/Circle
10. AO Code(under whom assessed last
8. Road/Street/Lane
9. Area/Locality
time)
Area Code
AO Type
Range Code
AO No.
12. State
11. Town/City/District
13. PIN
14. Last Assessment Year in which assessed
15. Email
16. Telephone No. (with STD
17. Present Ward/Circle
Code) and Mobile No.
18. Name of Business/Occupation
19. Present AO Code (if not same as above)
20. Jurisdictional Chief Commissioner of Income‐tax or Commissioner
Area Code
AO Type
Range Code
AO No.
of Income‐tax(if not assessed to Income‐tax earlier)
21. Estimated total income from the sources mentioned below
(Please tick the relevant box)
Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Income from units referred to in Schedule IV
The amount of withdrawal referred to in clause (a) of sub‐section 2 of section 80CCA referred to in Schedule V
22. Estimated total income of the previous year in which income mentioned in Column 21 is to be included
23.Details of investments in respect of which the declaration is being made:
SCHEDULE‐I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
Class of shares & face value of
No. of
Total value of shares
Distinctive numbers of the shares
Date(s) on which the shares were by the
each share
shares
acquired
declarant(dd/mm/yyyy)
NA
NA
NA
NA
NA
SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
Date(s) of securities
Description of securities
Amount of securities
Date(s) on which the securities were
Number of securities
(dd/mm/yyyy)
acquired by the declarant(dd/mm/yyyy)
SCHEDULE‐III
(Details of the sums given by the declarant on interest)
Name and address of the person to whom
Amount of sums
Date on which the sums were
Period for which such sums
Rate of
the sums are given on interest
given on interest
given on interest(dd/mm/yyyy)
were given on interest
interest
ICICI Bank Ltd.
Cust ID :
Fixed Deposit Numbers:
SCHEDULE‐IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the
Number of units
Class of units and face
Income in respect of units
Distinctive number of units
mutual fund
value of each unit
NA
NA
NA
NA
NA
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