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

FORM NO.15G

[See section 197A(1), 197A(1A) and rule 29C]

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Declaration under section 197A(1) and section 197A (1A) of the Income tax Act, 1961 to be made by an individual or a person

(not being a company or firm) claiming certain receipts without deduction of tax.

PART-I

1] Name of Assessee (Declarant) :

2]PAN of the Assessee :

3] Assessment Year

(for which declaration is being made)

4] Flat / Door / Block No. :

5] Name of Premises :

7] Assessed in which Ward / Circle

6] Status :

8] Road / Street / Lane :

9] Area / Locality :

10] AO Code (under whom assessed last time) :

Area Code

AO Type

Range Code

AO No.

11] Town / City / District :

12] State :

14] Last Assessment Year in

13] PIN

which assessed :

15] Email :

16] Telephone (with STD code) /

17] Present Ward / Circle

Mobile No :

18] Residential Status :

(within meaning of

Resident

Section 6 of the Income

Tax Act, 1961)

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 which income mentioned in Col - 22 to be included :

24] Details of investments in respect of which the declaration is being made :

SCHEDULE-I (Please see on the reverse)

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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 securities were

securities

(dd/mm/yyyy)

acquired by declarant (dd/mm/yyyy)

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SCHEDULE III

(Details of the sums given by the declarant on interest)

Date on which the sums

Name and address of the person to

Amount of sums

Period for which sums

were given on interest

Rate of interest

whom the sums are given on interest

given on interest

were given on interest

(dd/mm/yyyy)

SCHEDULE - IV (Please see on reverse)

SCHEDULE - V (Please see on reverse)

Signature of the Declarant

Declaration / Verification

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

* I

W e

d o

h e r e b y

d e c l a r e

t h a t

t o

t h e

b e s t

o f

* my / our knowledge and belief what is stated above is correct, complete and is truly stated. *I /We declare 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 Income Tax Act, 1961. *I/We further, declare that tax on *my / our estimated total income, including *income / incomes referred to in column 22 above, computed in accordance with provisions

of the Income Tax Act, 1961, for the previous year ending on

_________

relevant to the assessment year ____________ will be nil. *I / We also, declare that *my / our *income / incomes referred to in

Column 22 for the previous year ending on

_________

relevant to the assessment year

__________

will not exceed the maximum amount which is not chargeable to income tax.

Place : _________

Signature of the Declarant

PART - II

Date : _________