Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax 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
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2"FORM NO. 15H
[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.
PART‐I
1. Name of Assessee (Declarant)
2. PAN of the Assessee
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
10. AO Code(under whom assessed last
8. Road/Street/Lane
9. Area/Locality
time)
Area Code
AO Type
Range Code
AO No.
11. Town/City/District
12. State
13. PIN
14. Last Assessment Year in which assessed
15. Email
16. Telephone No. (with STD Code) and Mobile No.
17. Present Ward/Circle
18. Name of Business/Occupation
19. Present AO Code (if not same as above)
Area Code
AO Type
Range Code
AO No.
20. Jurisdictional Chief Commissioner of Income‐tax or Commissioner of Income‐tax(if 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
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
Class of shares &
Distinctive numbers of
Date(s) on which the shares were acquired by the
No. of
Total value
face value of each
shares
of shares
the shares
declarant(dd/mm/yyyy)
share
SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
Date(s) of
Description of
Amount of
Date(s) on which the securities were acquired by the
Number of securities
securities
securities
securities
declarant(dd/mm/yyyy)
(dd/mm/yyyy)
SCHEDULE‐III
(Details of the sums given by the declarant on interest)
Name and address of the
Amount of
Date on which the sums were
Period for which such sums were
Rate of
person to whom the sums are
sums given
given on interest(dd/mm/yyyy)
given on interest
interest
given on interest
on interest
SCHEDULE‐IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the
Number of
Class of units and face
Income in respect of
Distinctive number of units
mutual fund
units
value of each unit
units
SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
The amount of
Particulars of the Post Office where the account under the National
Date on which the account was
withdrawal from the
Savings Scheme is maintained and the account number
opened(dd/mm/yyyy)
account
Printed from
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