"FORMNO.15H [Seesection197A(1C)andrule29C(1A)] Declarationundersection197A(1C)oftheIncometaxAct,1961tobemadebyanindividualwhoisoftheageofsixtyyearsormoreclaimingcertainreceipts withoutdeductionoftax. PARTI 1.NameofAssessee(Declarant) 2.PANoftheAssessee 3.Age 5.Flat/Door/BlockNo. 8.Road/Street/Lane 6.NameofPremises 9.Area/Locality 4.AssessmentYear (forwhichdeclarationisbeingmade) 7.

AssessedinwhichWard/Circle 10.AOCode(underwhomassessedlast time)

AONo.

AreaCode AOType RangeCode

11.Town/City/District

12.State 13.PIN 14.LastAssessmentYearinwhichassessed 17.PresentWard/Circle

15.Email

16.TelephoneNo.(withSTDCode)andMobileNo.

19.PresentAOCode(ifnotsameasabove) 18.NameofBusiness/Occupation AONo. 20.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessed AreaCode AOType RangeCode toIncometaxearlier) (Pleaseticktherelevantbox) DividendfromsharesreferredtoinScheduleI InterestonsecuritiesreferredtoinScheduleII InterestonsumsreferredtoinScheduleIII IncomefromunitsreferredtoinScheduleIV Theamountofwithdrawalreferredtoinclause(a)ofsubsection2ofsection80CCAreferredtoinScheduleV 22.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn21istobeincluded 21.Estimatedtotalincomefromthesourcesmentionedbelow 23.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade: SCHEDULEI (Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim) Classofshares& Date(s)onwhichtheshareswereacquiredbythe No.of Totalvalue Distinctivenumbersof facevalueofeach theshares declarant(dd/mm/yyyy) shares ofshares share

Descriptionof securities

SCHEDULEII (Detailsofthesecuritiesheldinthenameofdeclarantandbeneficiallyownedbyhim) Date(s)of Date(s)onwhichthesecuritieswereacquiredbythe Amountof Numberofsecurities securities declarant(dd/mm/yyyy) securities (dd/mm/yyyy)

SCHEDULEIII (Detailsofthesumsgivenbythedeclarantoninterest) Nameandaddressofthe Amountof Dateonwhichthesumswere Periodforwhichsuchsumswere persontowhomthesumsare sumsgiven givenoninterest(dd/mm/yyyy) givenoninterest givenoninterest oninterest

Rateof interest

SCHEDULEIV (Detailsofthemutualfundunitsheldinthenameofdeclarantandbeneficiallyownedbyhim) Incomeinrespectof Nameandaddressofthe Numberof Classofunitsandface Distinctivenumberofunits units valueofeachunit mutualfund units

SCHEDULEV (DetailsofthewithdrawalmadefromNationalSavingsScheme) ParticularsofthePostOfficewheretheaccountundertheNational SavingsSchemeismaintainedandtheaccountnumber Dateonwhichtheaccountwas opened(dd/mm/yyyy) Theamountof withdrawalfromthe account

SignatureoftheDeclarant

Declaration/Verification

I.do hereby declare that I am resident in India within the meaning of section 6 of the Incometax Act, 1961. I also, hereby declare that to the best of my knowledge and belief what is stated above is correct, complete and is truly stated and 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 Incometax Act, 1961. I further, declare that the tax on my estimated total income, including *income/incomes referred to in column 21 computed in accordance with the provisions of the Incometax Act, 1961, for the previous year ending on ....................relevanttotheassessmentyear..................willbenil. Place: Date: .. .. . SignatureoftheDeclarant

PARTII [Forusebythepersontowhomthedeclarationisfurnished] 2.PANofthepersonindicatedinColumn1ofPartII 1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn21ofPartI 3.CompleteAddress 4.TANofthepersonindicatedinColumn1ofPartII 5.Email 8.Dateonwhichdeclarationisfurnished (dd/mm/yyyy) 6.TelephoneNo.(withSTDCode)andMobileNo. 9.Periodinrespectofwhichthedividendhasbeen declaredortheincomehasbeenpaid/credited 7.Status 10.Amountofincomepaid 11.Dateonwhichthe incomehasbeenpaid/ credited(dd/mm/yyyy)

12.Dateofdeclaration,distributionorpaymentof dividend/withdrawalundertheNationalSavings Scheme(dd/mm/yyyy)

13.AccountnumberofNationalSavingsSchemefromwhichwithdrawalhasbeenmade

ForwardedtotheChiefCommissionerorCommissionerofIncometax

Place: Date:

.. .

. Signature of the person responsible for paying the income referred to in Column 21ofPartI

Notes: 1. Thedeclarationshouldbefurnishedinduplicate. *Deletewhicheverisnotapplicable. 2. 3. 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 statementin the declaration shall be liable to prosecution under 277 of the Incometax Act, 1961 and on conviction be punishable i) In a case where tax sought to be evaded exceeds twentyfive lakh rupees, with rigorous imprisonment which shall not be less than 6 months but whichmayextendtosevenyearsandwithfine; ii) 4. Inanyothercase,withrigorousimprisonmentwhichshallnotbelessthan3monthsbutwhichmayextendtotwoyearsandwithfine.

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 VIA, if any, for which the declarantiseligible.";