Notes: FORM NO.

15H
1. @ Give complete postal address. [See rule 29C(1A)]
Declaration
2. The declaration should under sub-section
be furnished (1C) of section 197A of the Income-tax Act,
in duplicate.
3. *Delete whichever
1961, toisbe notmade
applicable.
by an individual who is of the age of sixty-five years or
4. Before signing the verification, the declarantmore claiming
should satisfy
certainhimself
receipts
that
without
the deduction of tax
information furnished in the declaration is true, correct and complete in all
respects. AnyIperson
………..*son/daughter/wife
making a false statement of …….
in theresident of ….
declaration @ be
shall do hereby declare –
liable to prosecution under section 277 of the Income-tax Act, 1961, and on
conviction be punishable1. *that
- the shares/ securities/sums, particulars of which are given in the
Schedule
(i) below,
in a case wherestand in my name
tax sought to be and are exceeds
evaded beneficially
one owned by me, and
lakh rupees,
the dividend/
with rigorous interest in respect
imprisonment whichof such
shall*securities/sums
not be less than sixand/or income
months
in respect
but which of units
may is/aretonot
extend includible
seven years andin the
withtotal
fine;income of any other
person under sections (ii)60
in to
any64other
of the Income-tax
case, Act, 1961;
with rigorous imprisonment which shall not be less
than three months but which may extendOR to three years and with fine.
*that the particulars of my account under the National Savings Scheme PART II
and the amount of withdrawal [FORare USE BYthe
as per THE PERSON
Schedule TO WHOM THE DECLARATION IS FURNISHED]
below;
SCHEDULE
1.Description
Name and address
and of the Amount
person responsible
invested Date
for paying
of Estimated income
details
theof
income, mentioned in paragraph 1 of the *investment to be received
investment
declaration. /opening of
2. Date on which the declaration was furnished by the account
declarant.

3. Date of2. *declaration,

that my presentdistribution
occupation or ispayment
………;of
dividend/withdrawal from account number …..under
the National Savings
3. thatScheme.
I am of the age of years and am entitled to a deduction from
the amount of income-tax on my total income referred to in section 88B;
4. Period in respect of which *dividend has been
declared/interest is being4.credited
that the or
taxpaid/income in total income, including *income/incomes
on my estimated
respect
referredoftounits
in theisSchedule
being credited
belowor paid
computed in accordance with the
provisions of the Income-tax Act, 1961, for the previous year ending on
…… relevant to the assessment 5. Amount
year of *dividend/interest
...…..-…. will be nil; or income in respect of
units/withdrawal from National Saving Scheme Account.
5. that I have not been assessed to income-tax at any time in the past but I
fall within the jurisdiction6.of*Rate at which
the Chief interest or of
Commissioner income in respect
Income-tax …. of
or units, as
Commissioner of Income-tax ….; the case may be, is credited/paid.
Forwarded to the Chief Commissioner or Commissioner of Income-tax. …OR
Place ……..
that I was last assessed to income-tax for the assessment year …..…. by
………………
Date
the ……... Officer ……… Circle/Ward and the Permanent Account
Assessing
Signature of the person
Number allotted to me isresponsible
……..; for
paying the income referred to in
Paragraph 1
6. that I *am/am not resident in India within the meaning of section 6 of
the Income-tax Act, 1961;

……………
Signature of the declarant
Verification
I …. do hereby declare that to the best of my knowledge and belief what is stated
above is correct, complete and is truly stated.
Verified today, the ….. day of ….
Place ….. ……………
Signature of the declarant