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


[See Section 197A(1C) and Rule 29C(1A)]
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.
1. Name of Assessee (Declarant):
2. PAN of the Assessee :
Part - I
3. Age :
4. Assessment Year :
(For which declaration is being made)
5. Flat/ Door/ Block No.:
6. Name of Premises:
7. Assessed in which Ward / Circle :
8. Road/ Street/ Lane:
9. Area/ Locality:
10. AO Code:
( Under whom assessed last time)
Area Code
AO Type
Range Code
AO No.
12. State:
11. Town/ City/ District:
13. PIN:
14. Last Assessment year in which assessed:
15. Email
16. Telephone No. (with STD code) and
17. Present Ward/ Circle
Mobile No.:
18. Name of Business/ Occupation :
19. Present AO Code ( if not same as above)
20. Jurisdictional Chief Commissioner of Income tax or Commissioner of Income Tax ( if
Area Code
AO Type
Range Code
AO No.
not assessed to income-tax earlier)
21. 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 amount of withdrawal referred to in Clause (a) of Sub – section 2 of Section 80CCA referred to in schedule V
22. Estimated total income of the previous year in which income mentioned in column 21 is to be included
23. Details of investments in respect of which the declaration is being made:
Schedule I (Please see on the reverse)
Schedule II
(Details of the securities held in the name of the declarant and beneficially owned by him)
Description of
Number of Securities
Amount of Securities
Date(s) of securities
Date(s) on which the securities were acquired by
the declarant (dd/mm/yyyy)
Schedule III
(Details of the sums given by the declarant on interest)
Name & Address of the person to whom the sums are
Amount of sums given
Date on which the sums were
Period for which such
Rate of Interest
given on interest
on interest
given on interest (dd/mm/yyyy)
sums were given on
Schedule IV (Please see on the reverse)
Schedule V (Please see on the reverse)
Signature of the Declarant
Declaration/ Verification
_________________ 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 a previous year ending on 31
March ………………… relevant to the
Assessment year…………………… will be nil.
Signature of the Declarant
[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
7. Status:
No.4, Lady Desika Road, Mylapore, Chennai
Domestic Company
8. Date on which declaration is furnished
9. Period in respect of which the dividend has
10. Amount of Income
11. Date on which
No.: 044-24991363 / 24990356
been declared or the income has been paid/
the income has been
paid/ credited
12. Date of declaration, distribution or payment of dividend / withdrawal
13. Account number of National Savings Scheme from which
under the National Savings Scheme
withdrawal has been made:
Forwarded to Chief Commissioner or Commissioner of Income Tax…………………………………………………..
Signature of the person responsible for paying the
income referred to in column 21 of Part I


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