www.epfindia.gov.

in

मोबाईल सं
Mobile Number

कममचारी भविष्य विवि योजिा , 1952

EMPLOYEES’ PROVIDENT FUNDS SCHEME.1952
प्रपत्र -19 / Form-19
1. सदस्य का िाम / Name of the member

2. (क / a) वपता का िाम/ Father’s Name (क / a):

(ख / b):
(ख / b) पवत का िाम / Husband’s Name
3. जन्म वतवि / Date of Birth

4 फै क्ट्री/ स्िापिा का िाम ि पता / Name and Address of the Factory /

Establishment
5 (क / a): भविष्य विवि खाता सं. / P.F. Account No. (क / a):
.....................................................................................
(ख / b): यूवििसमल खाता संख्या (यू.ए.एि.) /Universal Account Number(UAN) (ख / b):
6 स्िापिा में प्रिेश की वतवि / Date of Joining the Establishment

7 िौकरी छोडिे की वतवि / Date of leaving Service

8 िौकरी छोडिे का कारण / Reason of leaving Service

....................................................................................................
- सेिा समाव‍त के कारण (क) सदस्य का खराब स्िास््य (ख) संकुचि / वियोक्ता का
व्यापार बंद होिे अििा ( ग ) अन्य कारण जो सदस्य के वियंत्रण से बाहर हैं , ....................................................................................................
Service terminated on account of (a) ill health of member (b)
Contraction /Discontinuation of employer’s business or (c) Other ....................................................................................................
Cause beyond the control of the member
....................................................................................................
- व्यवतगत कारण / Personal Reasons

9 *स्िायी खाता सं. ( पैि )

*Permanent Account No.(PAN) ....................................................................................................

*क्ट्या प्रपत्र संख्या 15 जी / 15 एच प्रस्तुत कर रहे हैं ( हााँ / िहीं )

....................................................................................................
* Whether submitting Form No. 15 G/15 H , if applicable (Yes/No)
कृ पया प्रपत्र 15 जी / 15एच की दो प्रवतयां संलग्न करें , ( यदद लागू है )
Please enclose two copies of Form No. 15G/15H, if applicable

* के िल 5 िर्म से कम की सेिा अिवि के मामले में/Only in case of service less than 5 years
10 पत्र-व्यिहार का पूरा पता / Full Postal address
....................................................................................................

....................................................................................................

....................................................................................................
Pin वपि..............................

11 भुगताि की विवि / Mode of payment: बचत बैंक खाता सं/Saving Bank Account No.
िांवछत दकसी एक कोष्टक में टिक लगाएं ( √ )
Put a ‘Tick’ against the one opted (√ ) …………………………………….………………………………….....

(क) मेरे खचम पर मविआडमर द्वारा अििा बैंक का िाम

(a) By Postal Money Order at my cost OR Name of Bank…………………………………………………………………
(ख) बचत खाता में रे खांदकत चैक/ इलेक्ट्त्राविक माध्यम से भुगताि
(b) By Account Payee Cheque/ Electronic Mode of payment शाखा का पता
Address of the Branch …………….………………………………
…………………….......................................................................
(अपिे बैंक खाते के रद्द चैक की एक प्रवत संलग्न करें / Please attach a copy of cancelled
आई.एफ एस.कोड
Cheque/Attested copy of first page of Pass Book )
IFS Code ………………………………………………………………

सदस्य द्वारा यह घोर्णा की जाती है दक िह दो माह से कहीं काम िहीं कर रहा है ( हााँ / िहीं ) / The member hereby declares that he has not been employed for two months (Yes/No.)

प्रमावणत दकया जाता है दक मेरी पूणम जािकारी के अिुसार उपरोक्त वििरण सही है / Certified that the particulars are true to the best of my knowledge.
प्रािी िे मेरे सामिे हस्ताक्षर दकए / अाँगूठा लगाया है / The Applicant has signed/thumb impressed before me.

सदस्य के हस्ताक्षर / Member’s Signature वियोक्ता के हस्ताक्षर / Employer’s Signature

अििा/ Or सदस्य का अाँगूठा विश।ि/ Member’s thumb impression वियोक्ता का पदिाम और मोहर / Designation & Seal of Employer

वतवि / Date ...............................

अिुलग्नक / Enclosures:
 अविम टिकि लगी रसीद ( के िल चैक द्वारा भुगताि होिे के मामले में प्रस्तुत की जाए)
ADVANCE STAMPED RECEIPT (To be furnished only in case of payments through cheque)

क्षेत्रीय भविष्य विवि आयुक्त से अपिे भविष्य विवि खाते के विपिाि पर `……................................................................ की रावश अपिे बचत बैंक खाते में प्राप्त की ।
Received a sum of `.…………………………..……………from Regional Provident Fund Commissioner by deposit in my Saving Bank account towards the

settlement of my Provident Fund Account .

Kindly do NOT paste revenue stamp in case of payments through NEFT / Electronic mode.
कृ पया एि.ई.एफ.िी. /इलेक्ट्राविक माध्यम से भुगताि होिे के मामले में रसीदी टिकि ि लगाएं।

एक रूपये की रसीदी टिकि एिं

हस्ताक्षर /
सदस्य का अाँगूठा विश।ि
Affix Re 1/- Revenue
stamp & signature/thumb
impression
.................................................................................................................
आयुक्त कायामलय के प्रयोग के वलए / ( For the use of Commissioner’s Office)

खाते का विपिाि दकया गया । फामम सं 21 –ए /2 तिा प्रत्याहरण रवजस्िर / 3 प.पै.वि. प्रपत्र 9 ( संशोवित ) में प्रविवष्ट की
Account settled in Part/Full Entered in F-21-A/2 and Withdrawal Register / Form 3 (F.P.F.) Form9 (Revised)

सा.सु.सहा. / SSA अिु. पयम. / SS

_________________________________________________________________________________________________________________________________________

भुगताि मद सं. मिीआडमर / चैक खाता सं.

P.I. No. M.O./ Cheque Account No.

के भुगताि के वलए पास दकया / Passed for payment for ` :………………………………. िी.डी.एस. /TDS Rate %: ……………

िी.डी.एस.रावश / TDS Amount ` :……………………………….

िी.डी.एस. के पश्चात् रावश/ Amount after TDS ` :……………………………….

मविआडमर कमीशि ( यदद कोई हो ) / M.O. Commission( if any) लेखा अविकारी

शुद्ध रावश मिीआडमर द्वारा दी जािी है / Net Amount to be paid by M.O. Accounts Officer

ददिांक/ Date :

( रोकड अिुभाग के प्रयोग के वलए ) / ( FOR USE IN CASH SECTION)

चैक सं ददिांक रोकड बही
Paid by cheque No…………………………………………………………Date …………………………………………………………Vide cash book
के खाता संख्या -10 मद िाम संख्या .................................................................................... द्वारा दकया गया ।
And Account No.10 Debit item No.

--------------------------------अिु.पयम. / SS -------------------------------------------------------------------------------------- स.आ/ A.PFC.----------------------------------------

अभ्युवक्तयां / REMARKS

____________________________________________________________________________________________________________________________________________

Claim ID/क्ट्लेम आई.डी. (for official use/कायामलय प्रयोग हेतु )

 eksckby la-@ Mobile Number

¼dsoy dk;kZYk; ds iz;ksxkFkZ½@ For Office Use Only

nkok la[;k@Clam I.D. …………………….....................

fudklh ifjYkkHk@;kstuk izek.ki= ds nkos gsrq iz;ksx fd;k tkus okyk izi= 10 lh
FORM 10C FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE
deZpkjh is”a ku ;kstuk] 1995 EMPLOYEES’ PENSION SCHEME, 1995
izi= Hkjus ls igys funsZ”kksa dks i<s+a@(Read the instructions before filing up this form)
;fn lnL;rk 180 fnu ¼xSj va”knk;h lsok dks NksM+ dj½] ls de dh gS rks izR;kgj.k ykHk ns; ugh gSaA WITHDRAWAL BENEFIT IS NOT ADMISSIBLE IF
MEMBERSHIP IS LESS THAN 180 DAYS EXCLUDING NON CONTRIBUTING PERIOD

1. ¼d½ lnL; dk uke ¼Li’V v{kjksa es½a @ Name of the Member (In Block Letters): ____________________________________________
¼[k½ nkosnkj dk uke
Name of the claimant (s): ______________________________________________________________________________

2. tUefrfFk@Date of Birth (dd/mm/yyyy)

3. firk dk uke /Father’s Name________________________________________________________________________________

ifr dk uke Husband’s Name (If applicable)___________________________________________________________________

4. LFkkiuk dk uke o irk ftlesa lnL; var esa fu;ksftr FkkA@ __________________________________________________________
Name & Address of the
Establishment in which, _______________________________________________________________________________
the member was last employed
5. dksM la- rFkk [kkrk la- {ks=@ dk dksM LFkkiuk dh dksM la- [kkrk la-
Code No. & Account No. Region/Off Code Estt. Code No. A/c No.

5A) dk;kZjaHk frfFk@Date of Joining the Estt. ___________________________________________________________________

6. lsok NksM+us dk dkj.k rFkk
lsok NksM+us dh frfFk ____________________________________________________________________________
Reason for leaving service &
Date of Leaving ___________________________________________________________________________
7. iwjk irk ¼Li’V v{kjksa es½a
Full Address (In Block Letters) ________________________________________________________________________

Jh@Jherh@dqekjh@Sh. /Smt. /Km. _______________________________________________________________________

iq=@iRuh@iq=h@S/o, W/o, D/o._________________________________irk@Adress _______________________________

______________________________________________________________________ fiu/PIN _____________________

# lnL; ds gLrk{kj vFkok ck,a@nk,a gkFk ds vaxwBs dk fu”kku # fu;ksDrk ds gLrk{kj /Employer’s Signature
Signature or Left / Right hand thumb impression of the member
Form 10C (www.epfindia.gov.in ) Page 1 of 4
 8. D;k vki fudklh ifjYkkHk ds LFkku ij ;kstuk gkWa Yes ugha No
izek.ki= Lohdkj djus ds fy, rS;kj gSaA
Are you willing to accept Scheme Certificate
in lieu of withdrawal benefits
;fn lnL;rk 180 fnu ¼xSj va”knk;h lsok dks NksM+ dj½] ls de dh gS rks izR;kgj.k ykHk ns; ugh gSaA
Withdrawal benefit is not admissible if the membership is less than 180 days excluding non contributory period of service.

9. ifjokj dk fooj.k ¼ifr@iRuh rFkk cPps rFkk ukfefr½

Particulars of Family (Spouse & Children & Nominee)
(flQZ ;kstuk izek.k i= ds fodYi ds fy,@applicable only for Scheme Certificate option)
uke tUe frfFk lnL; ds lkFk laca/k ukckfyd ds vfoHkkod dk uke
Name Date of Birth Relationship with Member Name of the guardian of minor
¼d½ ifjokj ds lnL;
(a) Family members

¼[k½ ukfefr
(b) Nomine
10. fcuk nkok fn, 58 o’kZ dh vk;q izkIr djus ds ckn lnL; dh e`R;q gksus ij] %&
In case of death of members after attaining the age of 58 years without filling the claim:-
¼d½ lnL; dh e`R;q dh frfFk@Date of death of the member

¼[k½ nkosnkjks ds uke@rFkk lnL; ls mldk laca/k@Name of the Claminant(s)/and relationship with the member

11. /kuizs’k.k dk ek/;e ¼fodfYir fof/k ds vuqlkj lacaf/kr dks’Vd esa fVd djsa½
Mode of remittance (put a tick in the box against the one opted)
¼d½ en la- 7 esa fn, irs ij esjh ykxr ij Mkd euhvkMZj }kjk
By postal money order at my cost to the address given against item No.7:
¼[k½ eq>s lwfpr djrs gq, esjs cpr [kkrk la-¼vuqlfw pr cSad@Mkd?kj½ esa js[kfdar psd@ bysDVªkWfud ek/;e ls vknkrk [kkrk lh/ks Hkstk tk,@ (b) By account
payees cheque/ electronic mode sent Directly for credit to my S.B. A/C (Scheduled Bank /P.O.) under intimation to me.

cpr CkSad [kkrk la+@aS.B. Account No. : ________________________________

cSad dk uke ¼Li’V v{kjksa esa@Name of the Bank (In Block Letters) : ________________________________

“kk[kk ¼Li’V v{kjksa es½a @Branch (In Block Letters) : ________________________________

vkbZ-,Q-,l-- dksM@ IFS Code : ________________________________
“kk[kk dk iwjk irk ¼Li’V v{kjksa es½a /Full address of the Branch (In Block Letters) : _______________________
(vius cSad [kkrs ds [kkyh@jÌ pSd dh ,d izfr layXu djsa Please attach a copy of cancelled/blank Cheque)

______________________________________________________________________________________
12. D;k vki d-is-a ;ks- 95 ds rgr is”a ku izkIr dj jgsa gSa \
Are you availing pension under EPS-95 \ gka@Yes ugha@No
;fn gkWa] rks bafxr djsa ih-ih-vks- la- fdlds }kjk tkjh
If yes, indicate PPO No………………. By whom issued………………………………………………………..

izekf.kr fd;k tkrk gS fd fooj.k esja s vf/kdre Kku ds vuqlkj lR; gS@
a Certified that the particulars are true to the best of my knowledge

lnL;@nkosnkj ds gLrk{kj vFkok ck,a gkFk ds vWaxwBs dk fu”kku

fnukad Signature or left Hand Thumb impression of the Member/Claimant
Date .......................

# fu;ksDrk ds gLrk{kj /Employer’s Signature

Form 10C (www.epfindia.gov.in ) Page 2 of 4

 vfxze izkfIr jlhn
Advance Stamped Receipt
¼dsoy Åij ¼[k½ ds ekeys esa gh izLrqr fd;k tk,½
[To be furnished only in case of (b) above]

is”a ku fuf/k [kkrs ds fuiVku Lo:i {ks=h; Hkfo’; fuf/k vk;qDr@mi&{ks=h; dk;kZy; ds izHkkjh vf/kdkjh ls vius cpr cSad [kkrs esa tek }kjk
₹ ----------------------------------------- ¼”kCnksa es½a --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------½ dh jkf”k izkIr dhA
Received a sum of ₹........................................ (Rupees.................................................................................) only from
Regional Provident Fund Commissioner/Officer-in-charge of Sub-Regional Office........................by deposit in my
savings Bank A/c towards the settlement of my Pension Fund Account.
ck¡;h rjQ fn, fjDr LFkku dks {ks=h; Hkfo’; fuf/k vk;qDr@izHkkjh vf/kdkjh }kjk Hkjk tk,xkA
The space should be left blank which shall be filled by Regional Provident Fund
Commissioner/Officer-in-charge)
₹ 1 jktLo fVdV

₹ 1 Revenue
fVdV ij lnL; ds gLrk{kj vkSj ck¡; gkFk ds vaxwBs dk fu”kku Stamp
Signature & left hand thumb impression of the member on the stamp

izEkkf.kr fd;k tkrk gS fd lnL; }kjk fn, fooj.k lgh gS vkSj lnL; us esjs le{k gLrk{kj fd, gSa@vaxwBk fu”kkuh yxkbZ gSA
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me.

lnL; dh etnwjh ,oa xSj va”knk;h lsokof/k ds fooj.k fuEukuqlkj gSa %&
The details of wages and period of non-contributory service of the member are as under:
¼izi=&3,@7½ ¼d-is-a ;ks-½ ml vof/k dk layXu gS ftl vof/k gsrq ;s deZpkjh Hkfo’; fuf/k dk;kZy; dks Hksts ugha x, FksA½
(Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employees’ Provident Fund Office)

fnukad 15-11-95 dks etnwjh ¼ewy osru + egaxkbZ HkÙkk½ ¼;fn ykxw gS½ ₹
Wages (Basic +D.A.) as on 15.11.95 (if applicable)
lsok R;kxus dh frfFk dks etnwjh
Wages as on the date of exit ₹

xSj v”knk;h lsok dh vof/k %

Period of non contributory Service :
o’kZ@ekg fnu
Year/Month No. of days

fnukad fu;ksDrk@izkf/kd`r vf/kdkjh ds gLrk{kj

Date .......................... Signature of Employer/Authorised Official

vk;qDr dk;kZy; ds iz;ksxkFkZ (For the use of commissioner’s office)

₹---------------------------------------------------------------------------------------------------- ds v/khu@vnk;xh en la- ---------------------------------------------------------------------------------------------------------- euhvkMZj@psd

Under ₹ .................................................................P.I.No.................................................................... M.O./Cheque.
₹ --------------------------------------------------------- “kCnksa esa ----------------------------------------------------------------------------------------------------------------------------- ------------------------- dh vnk;xh gsrq Lohd`r fd;kA

Passed for payment for ₹.......................... (in words) ..................................................................................................

euhvkMZj deh”ku ¼;fn dksbZ gS½ ------------------------------------------------------------------------------------------- fudklh ifjYkkHk dh fuoy jkf”k -----------------------------------------------------------------------------
M.O.Commission (if any) ....................................... net amount to be paid by M.O ............................ towards withdrawal
benefit.

lk-lq-l- vuqi;Zos{kd l-ys-vf/k-

SSA S.S. A.AO.

Form 10C (www.epfindia.gov.in ) Page 3 of 4

 ¼udnkuqHkkx ds iz;ksxkFkZ½
(For use in Cash Section)

psd la- ----------------------------------------------------------------------------------------------------------------------------- --------------- fnukad --------------------------------------- }kjk lans; ftls udn iqfLrdk ¼cSad½ [kkrk

la-&10 MSfcV en la- --------------------------------------------------------------------- ij ntZ dj fy;k gSA

Paid by inclusion in cheque No.............................. Dt ............................vide Cash Book (Bank) Account No.10 Debt
item No...............................................................

vuq i;Z- l- vf/k- ¼udn½

S.S AC (Cash)

,l- ,l- - tkjh djus ds fy, vkbZ- Mh- ,l layXu gS %&

For issue of S.C., IDS is enclosed

lk-lq-l- vuq- i;Z- l-ys-vk- l-Hk-fu-vk- ¼ys[kk½

SSA. S.S. A.AO. APFC (A/cs.)

¼is”a ku vuqHkkx ds iz;ksxkFkZ½

(For use in Pension Section)

;kstuk izke.ki= ftl ij fu;a=.k la- ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- mfYyf[kr gS] dks fnukad -------------

-------------------------------------------------------------------- dks tkjh fd;k vkSj bldh izfof’V ;kstuk izek.ki= fu;a=.k iath esa dhA

Scheme Certificate bearing the control No .....................................issued on ....................................................and

entered in the Scheme Certificate Control Register.

lk-lq-l-- vuq- i;Z- l-ys-vk- l-Hk-fu-vk- ¼ys[kk½

SSA S.S. A.AO. APFC (A/cs.)

Form 10C (www.epfindia.gov.in ) Page 4 of 4

 FORM NO. 15G
[See section 197A(1C), 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 Person (not being a company or firm) claiming certain receipts without deduction of tax.
PART - I
1] Name of Assessee (Declareant) : 2] PAN :
3] Assessment Year
6] Status :
4] Flat / Door / Block No. : 5] Name of Premises : 7] Assessed in which
Ward / Circle

8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (whom assessed last time) :

Area Code AO Type Range Code AO No.

11] Town / City / District :
15] Email :
19] Name of Business / Occupation :
12] State :
14] Last Assessment Year in
13] PIN which assessed :
16] Telephone / Mobile No : 17] Present Ward / Circle
18] Residential Status :
20] Present AO Code (if not same as above):

21] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax Area Code AO Type Range Code AO No.
(if not assessed to income tax earlier):

22] Estimated total income from the sources mentioned below: (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 from units referred to in Schedule - IV
The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
23] Estimated total income of the previous year in income mentioned in Col - 22 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 & face Total value Distinctive numbers Date on which the shares were acquired
shares value of each share of shares of the shares by the declarant (dd/mm/yyyy)

SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Date(s) of Date(s) on which the securitues were
Amount of securities
securities securities securities (dd/mm/yyyy) acquired by declarant (dd/mm/yyyy)

SCHEDULE‐III
(Details of the sums given by the declarant on interest)
Name and address of the person to Amount of sums Date on which sums given Period for which sums
Rate of interest
whom the sums are given on interest given on interest on Interest (dd/mm/yyyy) were given on interest
 SCHEDULE‐ IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Class of units & face Distinctive number
Name and address of the mutual fund Number of units Income in respect of units
value of each unit of units

SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account under the Date on which the account The amount of withdrawal
National Savings Scheme is maintained and the account number was opened (dd/mm/yyyy) from the account

x
Signature of the Declarant
Declaration / Verification

*I/ We do hereby declare that to the best of

knowledge and belief what is stated above is correct, complete and truly stated. *I /We declare that incomes referred to in this form are not includible in
the total income of any other person u/s 60 to 64 of Income Tax Act, 1961. *I/We further, declare that tax *on my / our estimated total income, including
*income / incomes referred to in column 22 above, computed in accordance with provisions of the Income Tax Act 1961. for the previous year ending on
31.03.20_ relevant to the relevant to the assessment year 20 - 20 __ will be nil.
*I / We also, declare that *my / our *income / incomes referred to in Column 22 for the previous year ending on 31.03.20 __ relevant to the
assessment year 20 - 20___ will not exceed the maximum amount which is not chargeable to income tax.
Place : x
Date : Signature of the Declarant

PART - II
[For use by the person to whom the declaration is furnished]
1] Name of the person responsible for paying the income referred to in Column 22 of
2] PAN of the person indicated in Column 1 of Part II
Part I :

3] Complete Address : 4] TAN of the person indicated in

Column 1 of Part II :

5] Email : 6] Telephone / Mobile No : 7] Status :

8] Date on which Declaration is
Furnished (dd/mm/yyyy) :
9] Period in respect of which the dividend 10] Amount of
income paid : 11] Date on which the income has been
has been declared or the income has been
paid / credited (dd/mm/yyyy) :
paid / credited :

12] Date of declaration, distribution or payment of

13] Account Number of National Saving Scheme from which withdrawal has been
dividend/withdrawal under the National Savings
made :
Scheme(dd/mm/yyyy) :

Forwarded to the Chief Commissioner or Commissioner of Income‐tax ____________

Place : Signature of the person responsible for paying the

Date : income referred to in Column 21 of Part I
 FORM NO. 15G
[See section 197A(1C), 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 Person (not being a company or firm) claiming certain receipts without deduction of tax.
PART - I
1] Name of Assessee (Declareant) : 2] PAN :
3] Assessment Year
6] Status :
4] Flat / Door / Block No. : 5] Name of Premises : 7] Assessed in which
Ward / Circle

8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (whom assessed last time) :

Area Code AO Type Range Code AO No.

11] Town / City / District :
15] Email :
19] Name of Business / Occupation :
12] State :
14] Last Assessment Year in
13] PIN which assessed :
16] Telephone / Mobile No : 17] Present Ward / Circle
18] Residential Status :
20] Present AO Code (if not same as above):

21] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax Area Code AO Type Range Code AO No.
(if not assessed to income tax earlier):

22] Estimated total income from the sources mentioned below: (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 from units referred to in Schedule - IV
The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
23] Estimated total income of the previous year in income mentioned in Col - 22 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 & face Total value Distinctive numbers Date on which the shares were acquired
shares value of each share of shares of the shares by the declarant (dd/mm/yyyy)

SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Date(s) of Date(s) on which the securitues were
Amount of securities
securities securities securities (dd/mm/yyyy) acquired by declarant (dd/mm/yyyy)

SCHEDULE‐III
(Details of the sums given by the declarant on interest)
Name and address of the person to Amount of sums Date on which sums given Period for which sums
Rate of interest
whom the sums are given on interest given on interest on Interest (dd/mm/yyyy) were given on interest
 SCHEDULE‐ IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Class of units & face Distinctive number
Name and address of the mutual fund Number of units Income in respect of units
value of each unit of units

SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account under the Date on which the account The amount of withdrawal
National Savings Scheme is maintained and the account number was opened (dd/mm/yyyy) from the account

x
Signature of the Declarant
Declaration / Verification

*I/ We do hereby declare that to the best of

knowledge and belief what is stated above is correct, complete and truly stated. *I /We declare that incomes referred to in this form are not includible in
the total income of any other person u/s 60 to 64 of Income Tax Act, 1961. *I/We further, declare that tax *on my / our estimated total income, including
*income / incomes referred to in column 22 above, computed in accordance with provisions of the Income Tax Act 1961. for the previous year ending on
31.03.20_ relevant to the relevant to the assessment year 20 - 20 __ will be nil.
*I / We also, declare that *my / our *income / incomes referred to in Column 22 for the previous year ending on 31.03.20 __ relevant to the
assessment year 20 - 20___ will not exceed the maximum amount which is not chargeable to income tax.
Place : x
Date : Signature of the Declarant

PART - II
[For use by the person to whom the declaration is furnished]
1] Name of the person responsible for paying the income referred to in Column 22 of
2] PAN of the person indicated in Column 1 of Part II
Part I :

3] Complete Address : 4] TAN of the person indicated in

Column 1 of Part II :

5] Email : 6] Telephone / Mobile No : 7] Status :

8] Date on which Declaration is
Furnished (dd/mm/yyyy) :
9] Period in respect of which the dividend 10] Amount of
income paid : 11] Date on which the income has been
has been declared or the income has been
paid / credited (dd/mm/yyyy) :
paid / credited :

12] Date of declaration, distribution or payment of

13] Account Number of National Saving Scheme from which withdrawal has been
dividend/withdrawal under the National Savings
made :
Scheme(dd/mm/yyyy) :

Forwarded to the Chief Commissioner or Commissioner of Income‐tax ____________

Place : Signature of the person responsible for paying the

Date : income referred to in Column 21 of Part I