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Form No. 15h - 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 Page 4

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

2. PAN of the person indicated in

in Column 22 of Part I

Column 1 of Part II

BANK OF BAHRAIN & KUWAIT B.S.C.

AAACB2140F

3. Complete Address

4. TAN of the person indicated in

Bank of Bahrain & Kuwait BSC

Column 1 of Part II

Jolly Maker Chamber II,

225, Nariman Point,

Mumbai – 400 021.

MUMB11644D

5. Email

6. Telephone No. (with STD Code) and

Mobile No. (022)

22823698 / 99

7. Status Domestic Company

8. Date on which Declaration

9. Period in respect of which the

10. Amount of

11. Date on which the

is Furnished

dividend has been

income paid

income has been paid/

(dd/mm/yyyy)

declared or the income has been

credited(dd/mm/yyyy)

paid/credited

12. Date of declaration, distribution or payment of

13. Account Number of National Saving Scheme from

dividend/withdrawal under the

which withdrawal has been made

National Savings Scheme(dd/mm/yyyy) N.A.

N.A.

Forwarded to the Chief Commissioner or Commissioner of Income-

tax…………………………………………………………

Place : ……………………………………..

Date : ………………………………………..

……………………………….

Signature of the person responsible

for paying the income referred in

column 21 of Part I

Notes:

1. The declaration should be furnished in duplicate.

*Delete whichever is not applicable.

Before signing the declaration/verification , the declarant should satisfy himself that the

information furnished in this form is true, correct and complete in all respects. Any person

making a false statement in the declaration shall be liable to prosecution under 277 of the

Income-tax Act, 1961 and on conviction be punishable-

1. 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;

2. 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.

Form No. 15h - 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 Page 4

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