Bar Code: [ LI] ‘1110000001 I vx (TTT FORM NO. 15H. [See section 197A(1C) and rule 29C] Declaration under section 197A(1C) to be made by an individual who is of the age of sixty years or more dlaiming certain incomes without deduction of tax. PARTI T Name of Assescee (Declarariy TD PAN ofthe Assewee” | 3, Date of Binh (@D/MM/YYYY) a Previous year?) (or which ‘5 Flat/Door/Block No, © Name af Premises declaration is being made) 7.Road/StreetLane | 8. Area/Locality 9. Town/Giny/District | 10. State TL PIN 12, Email 15. Telephone No. (with STD Code) and Mobile No. Ta @ Whahe mmesediota Velo] {b) I yes, latest assessment year For which asessed WIT TS, Estimated income for which this declaration ts ‘made 16, Fstinwated total income of the P.Y. in which income mentioned in column 15 to be included” 17, Detail of Form No.1 SH other than this Termn filed for the previous yeas, any Total No, of Form No. 15H filed ‘Agaregite amount of income for which Form No ISH filed TS, Details of income for which the declaration is fled SI] ldentification number of No. | relevant investment/account, etc.” ‘Nature of income Section under which tax is deductible ‘Amount of income EDFOBANK LTD ocusTID: © FDNO © FDNO SFDNO OFDNO SFDNO © FDNO © FDNO erz.s02018 r : Signature af the Declarant ‘Mandatory : To be filed by the Branch (Cuecatst for Form 18 H (Far individual >= 60 years) Thave chested and confirm the below rekon) ‘Customer is — 60 years (if <60 years then fil fox 15 0) ‘Wa undertand your word PAN No. is updatedin Bank Records against the Cust id of customer ‘Copy of PAN Card attached (if not updated inthe system) aN (Branch ‘Customer has signed in six places (indicated by) E> Seal with Fields marked © are mandatory tobe filled Date ‘Name of the Emp Emp. Code Emp. Sign DsDeclaration’ Verification® L do hereby declare that Tam resident in India within the meaning of section 6 of the TIncome-tax Act, 1961. T also hereby declare that to the best of my knowledge and belief what is stated above is comect, 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 under sections 60 to 64 of the Incomestax Act, 1961. [further declare that the tx on my cstimated total income including *incomelincomes referred to in column 1S *and aggregate amount of *incomesincomes referred to in colutnm 17 computed in accordance withthe provisions of the Income-tax Act, 1961, for the previous year ending on relevant to the assessment year. -will beni wr Phace: Signature of the Declarant Date PARTIE [To he filled by the person responsible for paying the income referred to in column 15 of Part I] [Nene of the panian reaponible far paying © Unique Identification No. 3. PAN of the person Tesponsible Tor [4 Complete Address] 5. TAN of the pawson responsible for paying paying 6 Email 7, Telephone No. (with STD Code) and Mobile | 8 Amount of income paid” No. 9._Date an which Declaration is received | 10, Date on which the income has been paid/credited ODMMYYYY) @DMMYYYY) "Signature ofthe person responsible for paying Date the income referred to in column 15 of Part 1 Dales whichever ct apie ‘sper roms of cen 20680), the detec une ein (7TACIC) sll be i did ifthe dae a wld Ponce Acc Nabe (PAW. {Der can bs uisel by azeadent nde wins fthe age of yen or ore at ny ne ag the previous yar Sue Euaecalyea to uct acca pats ‘Hewesueion "Vor sfascsn! cat uss opronsensoflacwae ta Act 191 for ayy oe wisn ear ot os cseeaal yous pescing to You ia which he bela ie ed ‘Bisse neonon he annie ofsinad real come ofthe grevous parr ah the desLarsin (sled etig the anew fincas or eih as declan setae ‘tn cay dcinabont)n Frm No STs bled befre Hingas decarion donagthe ronous ye, mein he tld nner of sch Fonn Ne. 15H Ged ong wih he segeeee aunt efincone or vhich sat dversionsyhaveher ed “fea te snacto!wof ae, cad tle aaa dope ena eps: Nar Saray Soke, saeco pokey ae, cups cole ce ‘Ble Spring he derlarienveiBeaos th declan held ai mete then rmaon Esha oth oma str core camplete mall espe fay eee pla se eateneasin te etaraen stl iho psseosten uote secton 7 ofthe econo At, 161 ard oo conmion te goal (Oana towel sou obeevalel acess nay Stel rupees wbegeospuscame whch salon Velesstan ae otsbo la chnay cea seca yeas aden bor, {Go anp ei en thir ipamect nich dl nee Sm hea te hich may ne an pee an eth ie Uke penn rapt paping oe neem refered nin cal 89 Pat cl ot sequen ison numbered em e154 seve by eng ger fhe nan year and epoca urbe length he parte pein 3.) ft nan Fale, 1628 fe TDS vedere usher he aur quater case tie pon has du feceved fom Ne 10 dag he sue quae, les lt spare ses of end woah Ei Poa No 15 aud Fon e150 {OTe erm pense yee se fo oi cal 3 of Pata ate th dean he ean of pesto af hace eer in sacicn [9 7A(CC) othe sense of arenas of ach ncome ede x psd ce Mey tab eed or gad Sana oe reins yer inch sch soca ists bese exeede ‘he tacen aot whic eat cares tac ate mag fn ebton() under Chater Vio fay wt feos any, we th bead “nce Hom ose oper? 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