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FORM NO 15G See section 197A 1 197A 1A and rule 29C Declaration under section 197A 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 firm claiming certain receipts without deduction of tax PART I 2 PAN of the Assessee 1 Name of Assessee Declarant 3 Assessment Year for which declaration is being made 4 Flat Door Block No 5 Name of Premises 8 Road Street Lane 9 Area Locality 11 Town City District 12 State 6 Status 7 Assessed in which Ward Circle 10 AO Code under whom assessed last time Area Code AO Type Range Code 13 PIN 15 Email 16 Telephone No with STD Code and Mobile No 19 Name of Business Occupation 21 Jurisdictional Chief Commissioner of Income tax or Commissioner of Income tax if not assessed to Income tax earlier 22 Estimated total income from the sources mentioned below AO No 14 Last Assessment Year in which assessed 17 Present Ward Circle 18 Residential Status within the meaning of Section 6 of the Income Tax Act 1961 20 Present AO Code if not same as above Area Code AO Type Range Code AO No 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 form units referred to in Schedule IV The amount of withdrawal referred to in section 80CCA 2 a from National Savings Scheme referred to in ScheduleV 23 Estimated total income of the previous year in which income mentioned in Column 22 is to be included 24 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 No of Class of shares Total value Distinctive numbers of the shares shares face value of each Date s on which the shares were acquired by the of shares share declarant dd mm yyyy Description of securities SCHEDULE II Details of the securities held in the name of declarant and beneficially owned by him Date s of Date s on which the securities were Number of securities securities Amount of securities acquired by the 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 person to whom the sums are sums given given on interest on interest Date on which the sums were given on interest dd mm yyyy Period for which sums were given on interest Rate of 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 Income in respect of Number of Class of units and face value of each Distinctive number of units mutual fund unit units units SCHEDULE V Details of the withdrawal made from National Savings Scheme Particulars of the Post Office where the account under the National Savings Scheme is maintained and the account number Printed from www incometaxindia gov in Date on which the account was opened dd mm yyyy The amount of withdrawal from the account Page 1 of 2
 FORM  NO.  15G  See  section  197A 1 ,    197A 1A   and  rule  29C  Declaration  under  section  197A 1   and  section  1...
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 accordance with the provisions of the Income tax Act 1961 for the previous year ending on relevant to the assessment year will be nil I We also declare that my our income incomes referred to in Column 22 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 the Declarant PART II For use by the person to whom the declaration is furnished 2 PAN of the person indicated in Column 1 of Part II 1 Name of the person responsible for paying the income referred to in Column 22 of Part I 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 No 8 Date on which Declaration is Furnished dd mm yyyy 9 Period in respect of which the dividend has been declared or the income has been paid credited 12 Date of declaration distribution or payment of dividend withdrawal under the National Savings Scheme dd mm yyyy 7 Status 10 Amount of income paid 11 Date on which the income has been paid credited dd mm yyyy 13 Account Number of National Saving Scheme from which withdrawal has been made Forwarded to the Chief Commissioner or Commissioner of Income tax Place Date Signature of the person responsible for paying the income referred to in Column 22 of Part I Notes 1 2 3 4 5 The declaration should be furnished in duplicate Delete whichever is not applicable Declaration can be furnished by an individual under section 197A 1 and a person other than a company or a firm under section 197A 1A Indicate the capacity in which the declaration is furnished on behalf of a HUF AOP etc Before signing the declaration verification the declarant should satisfy himself that the information furnished in this form is true correct and complete in all respects Any person making a false statement in the declaration shall be liable to prosecution under 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 6 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 3 months but which may extend to two years and with fine 6 The person responsible for paying the income referred to in column 22 of Part I shall not accept the declaration where the amount of income of the nature referred to in sub section 1 or sub section 1A of section 197A 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 Printed from www incometaxindia gov in Page 2 of 2
                                             .   Signature  of  the  Declarant Declaration Verification   I We            ...