Form No. 15g - Declaration Under Section 197a(1) And Section 197a (1a) Of The Incometax Act, 1961 To Be Made By An Individual Or Person (Not Being A Company Or Firm) Claiming Certain Receipts Without Deduction Of Tax

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FORM NO. 15G
[See section 197A(1C), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A (1A) of the Income‐tax Act, 1961 to be made by an individual or Person (not being a company or firm)
claiming certain receipts without deduction of tax.
PART – I
1] Name of Assessee (Declareant) :
2] PAN :
3] Assessment Year
6] Status :
4] Flat / Door / Block No. :
5] Name of Premises :
7] Assessed in
which Ward / Circle
8] Road / Street / Lane :
9] Area / Locality :
10] AO Code (whom assessed last time) :
Area Code
AO Type
Range Code
AO No.
11] Town / City / District :
12] State :
14] Last Assessment Year
13] PIN
in which assessed :
15] Email :
16] Telephone / Mobile No :
17] Present Ward / Circle
18] Residential Status :
Resident
19] Name of Business / Occupation :
20] Present AO Code (if not same as above):
Area Code
AO Type
Range Code
AO No.
21] Jurisdictional Chief Comm. of Income Tax or Comm. of
Income Tax (if not assessed to income tax earlier):
22] 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 amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
23] Estimated total income of the previous year in income mentioned in Col - 22 to be included :
24] 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)
No. of
Class of shares & face
Total value
Distinctive numbers
Date on which the shares were acquired
shares
value of each share
of shares
of the shares
by the declarant (dd/mm/yyyy)
SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of
Number of
Amount of
Date(s) of
Date(s) on which the securitues were
securities
securities
securities
securities (dd/mm/yyyy)
acquired by declarant (dd/mm/yyyy)
SCHEDULE‐III
(Details of the sums given by the declarant on interest)
Date on which sums
Name and address of the person to
Amount of sums
Period for which sums
Rate of
given
on Interest
whom the sums are given on interest
given on interest
were given on interest
interest
(dd/mm/yyyy)
D S KULKARNI DEVELOPERS
LTD.
DSK HOUSE 1187/60 J M
ROAD, SHIVAJINAGAR, PUNE
411005

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