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Dec SASAA 23512432 PDF
Dec SASAA 23512432 PDF
15G
[Seesection197A(1),197A(1A)andrule29C]
Declarationundersection197A(1)andsection197A(1A)oftheIncometaxAct,1961tobemadebyanindividualoraperson(notbeingacompanyorfirm)claiming
certainreceiptswithoutdeductionoftax.
PARTI
2.PANoftheAssessee
1.NameofAssessee(Declarant)
3.AssessmentYear
(forwhichdeclarationisbeingmade)
4.Flat/Door/BlockNo.
5.NameofPremises
8.Road/Street/Lane
9.Area/Locality
11.Town/City/District
12.State
6.#Status
7.AssessedinwhichWard/Circle
10.AOCode(underwhomassessedlast
time)
AreaCode AOType RangeCode
13.PIN
15.Email
16.TelephoneNo.(withSTDCode)andMobileNo.
19.NameofBusiness/Occupation
21.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessedto
Incometaxearlier)
22.Estimatedtotalincomefromthesourcesmentionedbelow:
AONo.
14.LastAssessmentYearinwhich
assessed
17.PresentWard/Circle
18.ResidentialStatus(withinthe
meaningofSection6oftheIncomeTax
Act,1961)
20.PresentAOCode(ifnotsameas
above)
AreaCode AOType RangeCode
AONo.
(Pleaseticktherelevantbox)
DividendfromsharesreferredtoinScheduleI
InterestonsecuritiesreferredtoinScheduleII
InterestonsumsreferredtoinScheduleIII
IncomeformunitsreferredtoinScheduleIV
Theamountofwithdrawalreferredtoinsection80CCA(2)(a)fromNationalSavingsSchemereferredtoinScheduleV
23.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn22istobeincluded
24.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade:
SCHEDULEI
(Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim)
No.of
Classofshares&
Totalvalue
Distinctivenumbersoftheshares
shares
facevalueofeach
Date(s)onwhichtheshareswereacquiredbythe
ofshares
share
declarant(dd/mm/yyyy)
Descriptionof
securities
SCHEDULEII
(Detailsofthesecuritiesheldinthenameofdeclarantandbeneficiallyownedbyhim)
Date(s)of
Date(s)onwhichthesecuritieswere
Numberofsecurities
securities
Amountofsecurities
acquiredbythedeclarant(dd/mm/yyyy)
(dd/mm/yyyy)
SCHEDULEIII
(Detailsofthesumsgivenbythedeclarantoninterest)
Nameandaddressofthe
Amountof
persontowhomthesumsare sumsgiven
givenoninterest
oninterest
Dateonwhichthesumsweregivenon
interest(dd/mm/yyyy)
Periodforwhichsumswere
givenoninterest
Rateof
interest
SCHEDULEIV
(Detailsofthemutualfundunitsheldinthenameofdeclarantandbeneficiallyownedbyhim)
Nameandaddressofthe
Incomeinrespectof
Numberof Classofunitsandfacevalueofeach
Distinctivenumberofunits
mutualfund
unit
units
units
SCHEDULEV
(DetailsofthewithdrawalmadefromNationalSavingsScheme)
ParticularsofthePostOfficewheretheaccountundertheNationalSavingsScheme
ismaintainedandtheaccountnumber
Dateonwhichtheaccount
wasopened(dd/mm/yyyy)
Theamountof
withdrawalfromthe
account
Page 1 of 2
.
**SignatureoftheDeclarant
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.
Place:
Date:
.
SignatureoftheDeclarant
..
..
PARTII
[Forusebythepersontowhomthedeclarationisfurnished]
2.PANofthepersonindicatedinColumn1ofPartII
1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn22ofPartI
3.CompleteAddress
4.TANofthepersonindicatedinColumn1ofPartII
5.Email
6.TelephoneNo.(withSTDCode)andMobileNo.
8.DateonwhichDeclarationisFurnished
(dd/mm/yyyy)
9.Periodinrespectofwhichthedividendhasbeen
declaredortheincomehasbeenpaid/credited
12.Dateofdeclaration,distributionorpaymentofdividend/withdrawalunderthe
NationalSavingsScheme(dd/mm/yyyy)
7.Status
10.Amountofincomepaid
11.Dateonwhichtheincome
hasbeenpaid/
credited(dd/mm/yyyy)
13.AccountNumberofNationalSavingSchemefromwhichwithdrawalhas
beenmade
ForwardedtotheChiefCommissionerorCommissionerofIncometax
Place:
Date:
..
.
Signatureofthepersonresponsiblefor
payingtheincomereferredtoin
Column22ofPartI
Notes:
1.
2.
3.
4.
5.
Thedeclarationshouldbefurnishedinduplicate.
*Deletewhicheverisnotapplicable.
#
Declarationcanbefurnishedbyanindividualundersection197A(1)andaperson(otherthanacompanyorafirm)undersection197A(1A).
**IndicatethecapacityinwhichthedeclarationisfurnishedonbehalfofaHUF,AOP,etc.
Beforesigningthedeclaration/verification,thedeclarantshouldsatisfyhimselfthattheinformationfurnishedinthisformistrue,correctandcompleteinall
respects.Anypersonmakingafalsestatementinthedeclarationshallbeliabletoprosecutionunder277oftheIncometaxAct,1961andonconvictionbe
punishable
i) Inacasewheretaxsoughttobeevadedexceedstwentyfivelakhrupees,withrigorousimprisonmentwhichshallnotbelessthan6monthsbutwhich
mayextendtosevenyearsandwithfine;
ii) Inanyothercase,withrigorousimprisonmentwhichshallnotbelessthan3monthsbutwhichmayextendtotwoyearsandwithfine.
6.
Thepersonresponsibleforpayingtheincomereferredtoincolumn22ofPartIshallnotacceptthedeclarationwheretheamountofincomeofthenaturereferred
toinsubsection(1)orsubsection(1A)ofsection197Aortheaggregateoftheamountsofsuchincomecreditedorpaidorlikelytobecreditedorpaidduringthe
previousyearinwhichsuchincomeistobeincludedexceedsthemaximumamountwhichisnotchargeabletotax.";
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