No.

of
shares
Totalvalue
ofshares
Amountofsecurities
Amountof
sumsgiven
oninterest
Rateof
interest
Numberof
units
SCHEDULEII
(Detailsofthesecuritiesheldinthenameofdeclarantandbeneficiallyownedbyhim)
Descriptionof
securities
Numberofsecurities
Date(s)of
securities
(dd/mm/yyyy)
Date(s)onwhichthesecuritieswere
acquiredbythedeclarant(dd/mm/yyyy)
SCHEDULEIII
(Detailsofthesumsgivenbythedeclarantoninterest)
Nameandaddressofthe
persontowhomthesumsare
givenoninterest
Dateonwhichthesumsweregivenon
interest(dd/mm/yyyy)
Periodforwhichsumswere
givenoninterest
Incomeinrespectof
units
SCHEDULEIV
(Detailsofthemutualfundunitsheldinthenameofdeclarantandbeneficiallyownedbyhim)
SCHEDULEV
Nameandaddressofthe
mutualfund
Classofunitsandfacevalueofeach
unit
Distinctivenumberofunits
Theamountofwithdrawalreferredtoinsection80CCA(2)(a)fromNationalSavingsSchemereferredtoinScheduleV
InterestonsecuritiesreferredtoinScheduleII
IncomeformunitsreferredtoinScheduleIV
Classofshares&
facevalueofeach
share
Distinctivenumbersoftheshares
DividendfromsharesreferredtoinScheduleI
17.PresentWard/Circle
20.PresentAOCode(ifnotsameas
above)
18.ResidentialStatus(withinthe
meaningofSection6oftheIncomeTax
Act,1961)
15.Email
(Pleaseticktherelevantbox)
19.NameofBusiness/Occupation
16.TelephoneNo.(withSTDCode)andMobileNo.
21.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessedto
Incometaxearlier)
AONo.
22.Estimatedtotalincomefromthesourcesmentionedbelow:
ParticularsofthePostOfficewheretheaccountundertheNationalSavingsScheme
ismaintainedandtheaccountnumber
Dateonwhichtheaccount
wasopened(dd/mm/yyyy)
Theamountof
withdrawalfromthe
account
24.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade:
(DetailsofthewithdrawalmadefromNationalSavingsScheme)
AONo.
9.Area/Locality 8.Road/Street/Lane
11.Town/City/District 12.State
14.LastAssessmentYearinwhich
assessed
"FORMNO.15G
[Seesection197A(1),197A(1A)andrule29C]
PARTI
7.AssessedinwhichWard/Circle
Declarationundersection197A(1)andsection197A(1A)oftheIncometaxAct,1961tobemadebyanindividualoraperson(notbeingacompanyorfirm)claiming
certainreceiptswithoutdeductionoftax.
6.
#
Status 4.Flat/Door/BlockNo. 5.NameofPremises
23.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn22istobeincluded
SCHEDULEI
(Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim)
Date(s)onwhichtheshareswereacquiredbythe
declarant(dd/mm/yyyy)
2.PANoftheAssessee
3.AssessmentYear
(forwhichdeclarationisbeingmade)
13.PIN
InterestonsumsreferredtoinScheduleIII
AreaCode AOType RangeCode
AOType RangeCode
1.NameofAssessee(Declarant)
10.AOCode(underwhomassessedlast
time)
AreaCode
Place:
Date:
Place:
Date:
Notes:
1.
2.
3.
4.
5.
i)
ii)
6.
**SignatureoftheDeclarant
12.Dateofdeclaration,distributionorpaymentofdividend/withdrawalunderthe
NationalSavingsScheme(dd/mm/yyyy)
13.AccountNumberofNationalSavingSchemefromwhichwithdrawalhas
beenmade
8.DateonwhichDeclarationisFurnished
(dd/mm/yyyy)
9.Periodinrespectofwhichthedividendhasbeen
declaredortheincomehasbeenpaid/credited
10.Amountofincomepaid 11.Dateonwhichtheincome
hasbeenpaid/
credited(dd/mm/yyyy)
1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn22ofPartI
3.CompleteAddress
.
Declaration/Verification
*I/Wedoherebydeclarethattothebestof*my/ourknowledgeandbeliefwhatisstatedaboveiscorrect,completeandistrulystated.*I/We
declarethattheincomesreferredtointhisformarenotincludibleinthetotalincomeofanyotherpersonu/s60to64oftheIncometaxAct,1961.*I/Wefurther,
declarethatthetax*onmy/ourestimatedtotalincome,including*income/incomesreferredtoinColumn22above,computedinaccordancewiththeprovisions
oftheIncometaxAct,1961,forthepreviousyearendingon....................relevanttotheassessmentyear..................willbenil.*I/Wealso,declarethat*my/our
*income/incomesreferredtoinColumn22forthepreviousyearendingon....................relevanttotheassessmentyear..................willnotexceedthemaximum
amountwhichisnotchargeabletoincometax.
SignatureoftheDeclarant
..
..
.
Signatureofthepersonresponsiblefor
payingtheincomereferredtoin
Column22ofPartI

.
6.TelephoneNo.(withSTDCode)andMobileNo.
7.Status
Thedeclarationshouldbefurnishedinduplicate.
Beforesigningthedeclaration/verification,thedeclarantshouldsatisfyhimselfthattheinformationfurnishedinthisformistrue,correctandcompleteinall
respects.Anypersonmakingafalsestatementinthedeclarationshallbeliabletoprosecutionunder277oftheIncometaxAct,1961andonconvictionbe
punishable
[Forusebythepersontowhomthedeclarationisfurnished]
*Deletewhicheverisnotapplicable.
#
Declarationcanbefurnishedbyanindividualundersection197A(1)andaperson(otherthanacompanyorafirm)undersection197A(1A).
Thepersonresponsibleforpayingtheincomereferredtoincolumn22ofPartIshallnotacceptthedeclarationwheretheamountofincomeofthenaturereferred
toinsubsection(1)orsubsection(1A)ofsection197Aortheaggregateoftheamountsofsuchincomecreditedorpaidorlikelytobecreditedorpaidduringthe
previousyearinwhichsuchincomeistobeincludedexceedsthemaximumamountwhichisnotchargeabletotax.";
Inacasewheretaxsoughttobeevadedexceedstwentyfivelakhrupees,withrigorousimprisonmentwhichshallnotbelessthan6monthsbutwhich
mayextendtosevenyearsandwithfine;
Inanyothercase,withrigorousimprisonmentwhichshallnotbelessthan3monthsbutwhichmayextendtotwoyearsandwithfine.
PARTII
2.PANofthepersonindicatedinColumn1ofPartII
4.TANofthepersonindicatedinColumn1ofPartII
ForwardedtotheChiefCommissionerorCommissionerofIncometax
..
5.Email
**IndicatethecapacityinwhichthedeclarationisfurnishedonbehalfofaHUF,AOP,etc.