— FORM NO. 15G [See section 197A(1), 197A(1A) and rule 290] Declaration under section 197A(1) and section 197A(1A) to be made oy an individual or & parson (not being @ company or firm) claiming cerain ncomes without deduction of tax PART - | 1. Name of Assessee (Declarant) 2 PANof the Assessee] AQIPP7885J Dhiren Kumar Panda 3. Status Married (4. Previous Year (PY) 6. Residential Satus 6. FlatiDoomBlock No. (for which declaration is being made) Permanent Bada Danda Sahi indian 7. Name of Premises 8. Road/Steevlane Angu | 9 Area/Localiy pO. Taratarini 410. Town city Distict Ganjam | 11-State_Odisha 12Pin 76404 Gujarat 4 15 Email [Link]@gmaiicom | 14 Tele No. (Wth STD Code) andM. No. 9893813450 46 (a) Whether assessed to tax under the Income-tax act 1961 | Yes | No. yas {) If yes, latest assessment year for which assessed 9999.93 16, Estimated income for which this decteration is made gQQO00I- 17 E-simaied total income of the PY. in which inceme mentioned in column 15 tobe included 99900. 418 Details of Form No. 15 other than this form filed during the previous year, if any Total No: of Form No. 15G filed ‘Aggregate amount of incame for which Form No. 18G filed 19. Details of incorre for which the declaration is fled S| Identification number of relevant | Nature of Income | Section under which tax is ‘Amount of Ineome No._|_ investmentiaccount, et. deductible Piru hasmar Famela- ~ Signature of the DeclarantDeclaration / Verification sie GAbram kanmman femelle: es nereby deciave that the best of my / our Anowleige and bole! whale sated above ls corre, camplte and s uly sated, * Uwe deca the! hencomes refered inthis fem ere ro inluble inthe total income of ary ctor poreon ul 60 t 64 of he income act, 191 * We futher. declare hat he tax “on myiou estimated foal income, including “ncame (Incas refered on Celummn 16 and aggregate amount of income” rca referred tin column 18 computed in acardance withthe provisions of he incomestax Act, 1961, forthe previcus year ending on ___2023____ relevant to the assessment year —2022.23 will be nil. “I / we also, declare that *my / cur “income /ineomes referred to In Column 16 and the aggreite amount of ncame/incemes referred to in eolumn 1 forthe previous year ending on 2023 evant to ne assessment yoa——2022-22 i not exceed the rapdnuan amount which tenet chargette t incor tn Place: _Bubaneswar Ghitumr torman fanwle Date 42/12/2023 * Signature of the Declarant PART - Il {Tobe filled by the person responsible for paying the Income referred to in column 16 of Parti] 1. Name of the person responsible for paying [Link] Identification No. S.K. DIST. CENTRAL CO. OP. BANK LTD. 3. PANof the person responsible for paying AAAAT1019P- [Link] Address. TAN of the person responsible for paying 6. Email 7. Telephone No, (with STO Code) and Mobile No. 8, Amount of income paid 9, Date 08 which Declaration is received (DDIMMIYY) 0 Date on which the inceme has been pad/credited (DDINMYY) Place Date: Signature of the person responsible for paying the income referred to in Column 18 of Part