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Form No. 15h - Declaration Under Section (1c) Section 197a Of The Income-Tax-Act, 1961, To Be Made By An Individual Who Is Of The Age Of Sixty Five Years Or More Claiming Certain Receipt Without Deduction Of Tax Page 2

NOTES :

@ Give complete Postal address.

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 be prosecuted under section

277 of the Income-tax Act, 1961, and on conviction be punishable :-

(i) in a case where the tax, to be evaded exceeds one lakh rupees, with rigorous imprisonment for a term 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 three years and with fine.

PART II

(FOR USE BY THE PERSON TO WHOM THE DECLARATION IS FURNISHED)

1. Name and address of the person

-----------------------------------------------------

responsible for paying interest on

-----------------------------------------------------

sums mentioned in paragraph 1

-----------------------------------------------------

of the declaration

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2. Date on which the declaration was

furnished by the declarant.

3. Date of *declaration, distribution or payment of

dividend/withdrawal from account number ................

under National Saving scheme

4. Period in respect of which * dividend has been declared/

interest is being credited or paid/income in respect of units

is being credited or paid.

5. Amount of * dividend / interest or income in respect of units

/withdrawal from under National Saving scheme

6. Rate at which interest is or incoming respect of units, as

the case may be, is credited/paid

Forwarded to the Chief Commissioner or Commissioner or Commissioner of Income-Tax

Place MUMBAI

Date ...............................

Signature of the person responsible

for paying interest other than

“interest on securities”

Form No. 15h - Declaration Under Section (1c) Section 197a Of The Income-Tax-Act, 1961, To Be Made By An Individual Who Is Of The Age Of Sixty Five Years Or More Claiming Certain Receipt Without Deduction Of Tax Page 2

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