FORMNO. 15H [See section 197A(1C) and role 29C] Declaration under section 197A(1C) to be made by an individual who is of the age of sisty years or more claiming certain incomes without deduction of tax. PARTI T, Namie of Assesses (Declarant) 72 PAN of the Assessee” | 3, Date of Barth” @DMMwyyy) 7 Previous year ¥) (lor which 3, Flat Doce Blodk No. © Name of Premises declaration is being made) 7 -RoadSieetLane | & ArealLowihty 9 TowalcayDiswiet | 10. Stave TL PIN 12 Smal 13. Telephone No. (with STD Code) and Mabile No. 13 (@ Whether asewed to tat Yes Be (b) If yes, latest assessment yef__} which asse{_] TS, Estimated income for which this declaraion i | 16, Eximated total icone of the PY. ia which meome nde snentioned in cohimn 15 tobe included? 7 Details of Fonn No 15H other tan this fonm Sled fr de previous ean ay? “Total No.of Form No.15H filed ‘Aggregate amount of mucome for which Fon No.1SH filed TS. Details of income for which the declaration is Bled ‘SL | Wenification number of | Nature of income Seotion under which | Amount ofincome No. [relevant investunent account, tae deductible ae ‘Siguatine ofthe Declarant Declaration Verification’ L soveneudo hereby declare that Tam resident in India within the meaning of section 6 of the Tncomestax Act, 1961, T also hereby declare that to the best of my knowledge and belief what is stated above is comeet, complete and is wuly stated and that the incomes refered to in this form axe not includible in the toral income of any other person under sections 60 to 64 ofthe Income-tax Act, 1961, T further declare thatthe tax on my estimated total income including "income incomes refered to in columa 1S “and aggregate amount of “income incomes refered to in column 17 computed in accordance with the provisions ofthe Tncome-tax Act, 1961 forthe previous yesr ending on relevant to the assessinent year svill be nl Place:. Signature ofthe Declarant Date: .PARTI [To be filled by the person vespousible for paying the income referred to in column 15 of Part I] T, Name of the parson responsible for paying ‘Unique [dentification No, 3. PAN of the paon repomible for 4 Complete Address [5 TAN of he pason repouable far paying Pas © Email 7. Telephaie No. (with STD Code) and Mobile | 8. Amount of income paid No, 9. Date on which Declaration is received | 10, Date on which the income has been paid credited opmMrnyyy) @DMMYYYY) Place: Signatwre of the person responsible for paying Date: the income referred to in column 15 of Past I *Delete whichever is not applicable "As per provisions of section 206AA(2), the declaration wader section 197A(AC) shall be invalid if the declarant {als to fumish his valid Permanent Accoust Number (PAN). Declaration can be finished by a tesiden: individual who is ofthe age of 60 years or more at any time during the prsvious year. "The financial year to which the income petains * Please mention “Yes" if assessed to tax ander the provisions of Income-tax Act, 1961 for any of the assessment 48" out of six assessment years preceding the year in which the deelration is filed. Please mention the amoiut of estimated toial income of the previous year for which the declaration is fled including the amouat of income for which his declaration is made. Sin case any declaration() in Form No, 15H is filed before filing this declaration during the previous yeu, mcution the otal uaube of such Foun No. 15H Gled uly with dae wygiegate uuu of inwvute for which said declarations) have been filed. “Mention the distinctive umber of shares, account number of term deposit, recurring deposit, National Savings Schemes, life insurance policy number, employee code. st. ‘Before signing the declaration verification, the declarant should satisfy himself that the information furnished in this form is tme, correct and complete in all respects. Any person making a false statement in the declaration shall be liable to prosecntion wider section 277 of the Income-tax Act. 1961 and on conviction be punishable- (@ in a case where tax sought to be evaded exceeds twenty-five lakh mpees. with rigorous imprisonment which shall not be less than six months but which may exend to seven years and with fine Gi in any other case, with rigorous imprisonment which shall not be less than three months but which may extend to two years and with fine. rhe person responsible for paying the income refered to in column 15 of Pat 1 shall allot « unique identification number to all the Form No. 15H received by him during a quarter cf the financial year and. report this reference number along with the particulars prescribed in rule 31A(4)(vii) of the Income-tax Rules, 1962 in the TDS statement furnished for the same quarter. In case the person has also received Fon No.15G during the same quarter. please allot separate series of serial number for Form No.1 SH and Fon No.15G. !The person responsible for paying the income referred to in column 15 of Past I shall not accept the declaration where the amcunt of income of the nature refered to in section 197A(IC) or the aggregate of the amounts of such income credited or paid or likely to be credited or paid during the previous year in ‘which such income is to be included exceeds the maximum amount which is not chargeuble to tax after allowing for deduction(s) under Chapter VI-A. if any, or set off of loss, if any, under the head “income from house property” for which the declarant is eligible. For deciding the eligibility, he is required to verify income or the aggregate amount of incomes, as the case may be, reported by the declarant in ‘columns 15 and 17.”.