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 Page 2
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1
2SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
The amount of withdrawal from the account
Particulars of the Post Office where the account under the National Savings
Date on which the account
Scheme is maintained and the account number
was opened(dd/mm/yyyy)
NA
NA
NA
….........................................................................
**Signature of the Declarant
Declaration/Verification
I ……………………………….…………………………….…………………………….…………… do hereby declare that I am
resident in India within the meaning of section 6 of the Income‐tax 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 Income‐tax
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 Income‐tax Act, 1961, for the previous year ending on
.................... relevant to the assessment year .................. will be nil.
Place
…………………………………
:
Date:
……………................................
…………………………………………
Signature of the Declarant
PART II
[For use by the person to whom the declaration is furnished]
1. Name of the person responsible for paying the income referred to in Column 21
2. PAN of the person indicated in Column 1 of Part II
of Part I
ICICI Bank Limited
AAACI1195H
3. Complete Address
4. TAN of the person indicated in Column 1 of Part II
5. Email
6. Telephone No. (with STD Code) and
Mobile No.
7. Status
8. Date on which declaration is furnished
9. Period in respect of which the
10. Amount of
11. Date on which the income
income paid
(dd/mm/yyyy)
dividend has been declared or the
has been paid /
income has been paid/credited
credited(dd/mm/yyyy)
12. Date of declaration, distribution or
13. Account number of National Savings Scheme from which withdrawal has
been made
payment of dividend/withdrawal under the
National Savings Scheme(dd/mm/yyyy)
Forwarded to the Chief Commissioner or Commissioner of Income‐tax…………………………………………………………
Place:
…………………………………
……………………………………………
……………................................
Date:
Signature of the person responsible for
paying the income referred to in Column
21 of Part I
Notes:
1.
The declaration should be furnished in duplicate.
2.
*Delete whichever is not applicable.
3.
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 Income‐tax Act, 1961 and on conviction be punishable‐
i)
In a case where tax sought to be evaded exceeds twenty‐five lakh rupees, with rigorous imprisonment which shall not be
less than 6 months but which may extend to seven years and with fine;
ii)
In any other case, with rigorous imprisonment which shall not be less than 3 months but which may extend to two years
and with fine.
4.
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 VI‐A, if any, for which the declarant is eligible.";
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