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 Page 2

Schedule I

(Details of shares, which stand in the name of the declarant and beneficially owned by him)

No. of shares

Class of Shares & Face Value of

Total Value of Share

Distinctive numbers of

Date(s) on which the shares were acquired by the

Each Shares

declarant (dd/mm/yyyy)

Schedule IV

(Details of the mutual fund units held in the name of the declarant and beneficially owned by him)

Name & Address of the Mutual Fund

No. of Units

Class of Unit and Face value of

Distinctive no. of Units

Income in

each unit

respect of units

Schedule V

(Details of withdrawal made from National Savings Scheme)

Particulars of Post Office where the account under the National Savings scheme is maintained and the

Date on which the account

The amount of

account number

was opened (dd/mm/yyyy)

withdrawal from account

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 statement in the declaration shall be liable to prosecution under section 277 of the Income Tax Act, 1961 and on

conviction be punishable –

(i)

In a case where tax sought to be evaded exceeds twenty five lakh rupees, with rigorous imprisonment which shall not be less than six 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 three 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.

FOR THE KIND ATTENTION OF DEPOSITORS

Incomplete forms are not accepted by the income tax authorities and therefore, could result in deduction of tax at source. Please therefore,

submit the form completed in all respects.

1. Income-tax, wherever applicable, will be deducted at source in accordance with the Income Tax Act, 1961, as amended to Date.

2. It may be noted that exemption from tax deduction will be granted only from the date of receipt of Form 15H and any tax deducted and remitted to the

government before that date will not be refunded by the company under any circumstances.

3. The amount of Income-tax deducted at source is remitted to the credit of Central Government before the 7th day of the following month. Any claim for

refund, will have to be made by the depositor to the income-tax authorities by filing a Return of Income.

4. Form 15H is a self declaratory form and does not require attestation by Govt. / Bank Official. However in case of thumb impression, the Form 15H should

be attested by a Bank official or by a Gazetted Officer.

5. Before returning the forms, depositors are requested to ensure that all the columns are duly filled up and that the signatures have been affixed.

6. Under the provisions of section 206AA, quoting of Permanent Account Number (PAN) in the declaration form 15G/H in Clause No.5 is mandatory for non-

deduction of Tax at Source. If PAN is not quoted in the declaration form, the form would be invalid and tax will be deducted at a higher rate of 20%.