1FORM NO.

15G

[See section 197A(1),197 A(1A) and rule 29C]

Declaration uncler section l97A(l) and section I97A(1A) to be made by an
individual or a persoll (not being a company or firrn) claiming certain
incomes without deduction of tax
PART I

1. Nan-rc of Assessee (Declaraiil) X r": v 4. r nJt- H 2. PAN of the Asscss NAe PS "r' I L{4 &
3. Status2 4. Preirious year(P.Y.)3 5. Residcntial Statusl
2-l -1--'s
(for lvlrich ieclaration is being macle; 20
Ttvlorwsu*t-
6. FIat/Doori Biock No. / \anlrt a)l rl'L-mtse's 8. Road/Street,/Lanc 9. Area./Locality $6 PP1 A6
1 0. Tori n / City / Districl }$itlot 311. State H P 12. PIN 4 y35-S-, 13. Ernail

14. Telephone No. (u,ith STD 15 (n) Wl-rether assessc.d to tax under tlie Yes No

Code) and N'Iobile No. Income-tar Act, 1961s:

+tq7-r7 3 Ls 7
(b) If ves, latest assessnlent vear lcr u'lrich assessed

16. Estimated incorne for lvhich Lhis declaration 17. Estirnated tol:ri income of the P.Y' in rvhicl'r
is rrade incc-rrt-tc meitlioned itr ccilumn 16 1.o be inclLrdccls

18. Detaiis of Form No. 15G other lhan this lorm liled during the previous J'ear, if anvT
Total No. of Form No. 15G filed Aggregate a[tounl of incomc for u'hich Forrl No'15G filed
*:.,

19. Details of incorte for u,hicli lhe declaration is filed

AI Idenlification number of reievant Naturrc oi irtcome Section under r'r,hich tax Anrount of urcomc
No. investntent,/ztccouni, etc.s is deductible

lo I 66 s-S*as* 6Lo PF -vtinaycL{..r.J 11z- n 3q"TT

t e Dec'f.arctnte

D e c lara tio n / Ve ri f i c a tio ttlo

-I/We....fi,5hy-....5nt-v..(rr.1r...."........",......... .mv/r:ur"knou'l-
clo herebl declare that to the best of
.I/We declare that
cdgc anci belief rvhat is stated abovc is corr"ect, cornplcte and is truly statcd.
in the total incorxe of anY othcr pcrsclrl
thclincomcs refcrrecl to in this form are not incluclible -I/We *on
Llnder sections 60 tr: 64 r:t the Income-tax Act, 1961. further dcclar:e that ttrc tax
*incomcfincomes refcrred to in colurnil 16 *ancl
my/our estimatccl tr-rt;rl incc.lrnc incluc[ing
*income/incomes rcferrcd to in column 18 computed in accordancc
aggrcgatc arrrolmt of
t["provisionsof the h'rcome-taxAct, lg6l,fortheprevious]'earerldingon.3l..f.nnr.rA.r.o.a
*mY/our l
"Iit
reler,antto thc assessment -vcar ..2v1'2::.AB.r-J rvill be nil..IlWe also declare that
.incomc/incomes referred io in column 16 .and tlre aggregate arxount r.;f .income/incomes
referred to in colurnn 18 for the previous .vear ending on ............. relevant to the
zrssessment vear ......... rviiinot exceed the maxilnum amount rvhich is not r:hargc-
zrblc to income-tax.

Signati,tre at' the l)eclarante

l. Substitutecl by IT (Four"teenth Amdt') Ruk's 29l-i, 1ii.e.['. 1-10-2015" Eadier^ Form No. 15G rvas
inserted b,v the IT (Fifth Anrdt.) Rules, 1982, rv.e.f .21-6-1982 and later on atnended bv the
IT (F'ifth nmdt.) Ruies, 1989, w.r.e.f. 1-4-1988, lT (For-u-teenth Amdt.) Rules, 1990, w"e.f.
20-11-1990 arrd IT (Trveif th Amdt.) Rules, 2002, w.e.f. 2l-b-2}02 and substituted bv the IT
(Eighth Amcit.)Rules, 2003, rv.c.f.9-6-2003 and iT (Sccond Amdt.) Ruies, 20i 3, lv.e.|.19-2-2AB