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

…………………………………………………………….

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 of Part I

2. PAN of the person indicated in Column 1 of Part II

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 dividend has been

10. Amount of income paid

11. Date on which the

(dd/mm/yyyy)

declared or the income has been paid/credited

income has been paid /

credited(dd/mm/yyyy)

12. Date of declaration, distribution or payment of

13. Account number of National Savings Scheme from which withdrawal has been made

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:

The declaration should be furnished in duplicate.

*Delete whichever is not applicable.

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‐

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.

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.";

Printed from

Page 2 of 2