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

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"FORM NO. 15G
[See
197A(1), 197A(1A) and rule 29C]

under
197A(1) and
197A(1A) of the Income-tax Act, 1961 to be made
an individual or a person (not being a
or
claiming
certain receipts without
of tax.
PART I
1. Name of Assessee (Declarant)
2. PAN of the Assessee
3. Assessment Year
( for which
is being made)
#
4. &


No.
5. Name of Premises
6.
Status
7. Assessed in which Ward/Circle
10. AO Code(under whom assessed last
8. Road/Street/Lane
9.
>
Area Code
AO d e Range Code
AO No.
11. d


t
12. State
13. PIN
14. Last Assessment Year in which
assessed
17. Present Ward/Circle
15. Email
16. Telephone No. (with STD Code) and Mobile No.
18. Z
Status ( within the
19. Name of 
K
meaning of ^
6 of the Income Tax
Act,1961)
20. Present AO Code (if not same as
above)
21. :
Chief Commissioner of Income-tax or Commissioner of Income-tax (if not assessed to
Area Code AO d e Range Code
AO No.
Income-tax earlier)
22. 
total income from the sources
below:
(Please
the relevant box)
Dividend from shares referred to in Schedule I
Interest on
referred to in Schedule II
Interest on sums referred to in Schedule III
Income form units referred to in Schedule IV
The amount of withdrawal referred to in
80CCA(2)(a) from E
Savings Scheme referred to in ScheduleV
23. 
total income of the previous
in which income
in Column 22 is to be included
24. Details of investments in respect of which the
is being made:
SCHEDULE-I
(Details of shares, which stand in the name of the declarant and
owned
him)
No. of
Class of shares &
Total value

numbers of the shares
shares
face value of each
Date(s) on which the shares were acquired
the
of shares
share
SCHEDULE-II
(Details of the
held in the name of declarant and
owned
him)
Date(s) of

of
Date(s) on which the
were
Number of
Amount of
acquired
the
SCHEDULE-III
(Details of the sums given
the declarant on interest)
Name and address of the
Amount of
Date on which the sums were given on
Period for which sums were
Rate of
person to whom the sums are
sums given
given on interest
interest
given on interest
on interest
SCHEDULE-IV
(Details of the mutual fund units held in the name of declarant and
owned
him)
Name and address of the
Class of units and face value of each
Income in respect of
Number of

number of units
mutual fund
unit
units
units
SCHEDULE-V
(Details of the withdrawal made from E
Savings Scheme)
The amount of
W
of the Post K
where the account under the E
Savings Scheme
Date on which the account
withdrawal from the
is maintained and the account number
was
account
……………………………………….
**Signature of the Declarant

s

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