Form 15g - Declaration Under Section 197(A)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 A Firm) Claiming Certain Receipts Without Deduction Of Tax Page 3

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SCHEDULE IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of
Number of
Class of units and
Distinctive number
Income in respect
the Mutual Fund
units
face value of each
of units
of units
unit
SCHEDULE V
(Details of the withdrawal made from National Saving Scheme)
Particulars of the Post Office where the account
Date on which the
The amount of withdrawal
under the National Savings Scheme is
account was opened
from the account
maintained and the account number
Signature of the declarant
Declaration/ Verification
*I/We_______________do hereby declare that to the best of *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 the income tax act, 1961. *I/We further declare that the tax
on *my/our estimated total income, including *income/incomes referred to in column 22 above, computed in
accordancewith the provisions of the income tax act, 1961 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:
Date:
Signature of Declarant

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