"FORMNO.

15G
[Seesection197A(1),197A(1A)andrule29C]
Declarationundersection197A(1)andsection197A(1A)oftheIncometaxAct,1961tobemadebyanindividualoraperson(notbeingacompanyorfirm)claiming
certainreceiptswithoutdeductionoftax.
PARTI
1.NameofAssessee(Declarant) 2.PANoftheAssessee
3.AssessmentYear
(forwhichdeclarationisbeingmade)
4.Flat/Door/BlockNo. 5.NameofPremises 6.#Status
7.AssessedinwhichWard/Circle
8.Road/Street/Lane 9.Area/Locality 10.AOCode(underwhomassessedlast
time)
AreaCode AOType RangeCode AONo.
11.Town/City/District 12.State
13.PIN 14.LastAssessmentYearinwhich
assessed
15.Email 16.TelephoneNo.(withSTDCode)andMobileNo. 17.PresentWard/Circle
18.ResidentialStatus(withinthe
19.NameofBusiness/Occupation meaningofSection6oftheIncomeTax
Act,1961)
20.PresentAOCode(ifnotsameas
above)
21.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessedto AreaCode AOType RangeCode AONo.
Incometaxearlier)
22.Estimatedtotalincomefromthesourcesmentionedbelow:
(Pleaseticktherelevantbox)
DividendfromsharesreferredtoinScheduleI
InterestonsecuritiesreferredtoinScheduleII
InterestonsumsreferredtoinScheduleIII
IncomeformunitsreferredtoinScheduleIV
Theamountofwithdrawalreferredtoinsection80CCA(2)(a)fromNationalSavingsSchemereferredtoinScheduleV
23.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn22istobeincluded

24.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade:
SCHEDULEI
(Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim)
No.of Classofshares&
Totalvalue
shares facevalueofeach Distinctivenumbersoftheshares Date(s)onwhichtheshareswereacquiredbythe
ofshares
share declarant(dd/mm/yyyy)

SCHEDULEII
(Detailsofthesecuritiesheldinthenameofdeclarantandbeneficiallyownedbyhim)
Date(s)of
Descriptionof Date(s)onwhichthesecuritieswere
Numberofsecurities Amountofsecurities securities
securities acquiredbythedeclarant(dd/mm/yyyy)
(dd/mm/yyyy)

SCHEDULEIII
(Detailsofthesumsgivenbythedeclarantoninterest)
Nameandaddressofthe Amountof
Dateonwhichthesumsweregivenon Periodforwhichsumswere Rateof
persontowhomthesumsare sumsgiven
interest(dd/mm/yyyy) givenoninterest interest
givenoninterest oninterest

SCHEDULEIV
(Detailsofthemutualfundunitsheldinthenameofdeclarantandbeneficiallyownedbyhim)
Nameandaddressofthe Numberof Classofunitsandfacevalueofeach Incomeinrespectof
Distinctivenumberofunits
mutualfund units unit units

SCHEDULEV
(DetailsofthewithdrawalmadefromNationalSavingsScheme)
Theamountof
ParticularsofthePostOfficewheretheaccountundertheNationalSavingsScheme Dateonwhichtheaccount
withdrawalfromthe
ismaintainedandtheaccountnumber wasopened(dd/mm/yyyy)
account
 .
**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]
1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn22ofPartI 2.PANofthepersonindicatedinColumn1ofPartII

3.CompleteAddress
4.TANofthepersonindicatedinColumn1ofPartII

5.Email 6.TelephoneNo.(withSTDCode)andMobileNo.
7.Status
8.DateonwhichDeclarationisFurnished 9.Periodinrespectofwhichthedividendhasbeen 10.Amountofincomepaid 11.Dateonwhichtheincome
(dd/mm/yyyy) declaredortheincomehasbeenpaid/credited hasbeenpaid/
credited(dd/mm/yyyy)

12.Dateofdeclaration,distributionorpaymentofdividend/withdrawalunderthe 13.AccountNumberofNationalSavingSchemefromwhichwithdrawalhas
NationalSavingsScheme(dd/mm/yyyy) beenmade

ForwardedtotheChiefCommissionerorCommissionerofIncometax

Place: ..
Date: .
Signatureofthepersonresponsiblefor
payingtheincomereferredtoin
Column22ofPartI

Notes:

1. Thedeclarationshouldbefurnishedinduplicate.
2. *Deletewhicheverisnotapplicable.
#
3. Declarationcanbefurnishedbyanindividualundersection197A(1)andaperson(otherthanacompanyorafirm)undersection197A(1A).
4. **IndicatethecapacityinwhichthedeclarationisfurnishedonbehalfofaHUF,AOP,etc.
5. Beforesigningthedeclaration/verification,thedeclarantshouldsatisfyhimselfthattheinformationfurnishedinthisformistrue,correctandcompleteinall
respects.Anypersonmakingafalsestatementinthedeclarationshallbeliabletoprosecutionunder277oftheIncometaxAct,1961andonconvictionbe
punishable
i) Inacasewheretaxsoughttobeevadedexceedstwentyfivelakhrupees,withrigorousimprisonmentwhichshallnotbelessthan6monthsbutwhich
mayextendtosevenyearsandwithfine;

ii) Inanyothercase,withrigorousimprisonmentwhichshallnotbelessthan3monthsbutwhichmayextendtotwoyearsandwithfine.
6. Thepersonresponsibleforpayingtheincomereferredtoincolumn22ofPartIshallnotacceptthedeclarationwheretheamountofincomeofthenaturereferred
toinsubsection(1)orsubsection(1A)ofsection197Aortheaggregateoftheamountsofsuchincomecreditedorpaidorlikelytobecreditedorpaidduringthe
previousyearinwhichsuchincomeistobeincludedexceedsthemaximumamountwhichisnotchargeabletotax.";