"FORMNO.15G [Seesection197A(1),197A(1A)andrule29C] Declarationundersection197A(1)andsection197A(1A)oftheIncometaxAct,1961tobemadebyanindividualoraperson(notbeingacompanyorfirm)claiming certainreceiptswithoutdeductionoftax. PARTI 2.PANoftheAssessee 1.NameofAssessee(Declarant) 3.AssessmentYear (forwhichdeclarationisbeingmade) 4.Flat/Door/BlockNo. 8.Road/Street/Lane 5.NameofPremises 9.Area/Locality 6.#Status 7.

AssessedinwhichWard/Circle 10.AOCode(underwhomassessedlast time)

AreaCode AOType RangeCode AONo.

11.Town/City/District

12.State 13.PIN 14.LastAssessmentYearinwhich assessed 17.PresentWard/Circle 18.ResidentialStatus(withinthe meaningofSection6oftheIncomeTax Act,1961) 20.PresentAOCode(ifnotsameas above)
AreaCode AOType RangeCode AONo.

15.Email 19.NameofBusiness/Occupation

16.TelephoneNo.(withSTDCode)andMobileNo.

21.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessedto Incometaxearlier) 22.Estimatedtotalincomefromthesourcesmentionedbelow:

(Pleaseticktherelevantbox) DividendfromsharesreferredtoinScheduleI InterestonsecuritiesreferredtoinScheduleII InterestonsumsreferredtoinScheduleIII IncomeformunitsreferredtoinScheduleIV Theamountofwithdrawalreferredtoinsection80CCA(2)(a)fromNationalSavingsSchemereferredtoinScheduleV 23.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn22istobeincluded 24.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade: SCHEDULEI (Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim) No.of Classofshares& Totalvalue shares Distinctivenumbersoftheshares facevalueofeach Date(s)onwhichtheshareswereacquiredbythe ofshares share declarant(dd/mm/yyyy)

Descriptionof securities

SCHEDULEII (Detailsofthesecuritiesheldinthenameofdeclarantandbeneficiallyownedbyhim) Date(s)of Date(s)onwhichthesecuritieswere Numberofsecurities securities Amountofsecurities acquiredbythedeclarant(dd/mm/yyyy) (dd/mm/yyyy)

SCHEDULEIII (Detailsofthesumsgivenbythedeclarantoninterest) Nameandaddressofthe Amountof persontowhomthesumsare sumsgiven givenoninterest oninterest Dateonwhichthesumsweregivenon interest(dd/mm/yyyy) Periodforwhichsumswere givenoninterest Rateof interest

SCHEDULEIV (Detailsofthemutualfundunitsheldinthenameofdeclarantandbeneficiallyownedbyhim) Nameandaddressofthe Incomeinrespectof Numberof Classofunitsandfacevalueofeach Distinctivenumberofunits mutualfund unit units units

SCHEDULEV (DetailsofthewithdrawalmadefromNationalSavingsScheme) ParticularsofthePostOfficewheretheaccountundertheNationalSavingsScheme ismaintainedandtheaccountnumber Dateonwhichtheaccount wasopened(dd/mm/yyyy) Theamountof withdrawalfromthe account

. **SignatureoftheDeclarant Declaration/Verification

*I/Wedoherebydeclarethattothebestof*my/ourknowledgeandbeliefwhatisstatedaboveiscorrect,completeandistrulystated.*I/We declarethattheincomesreferredtointhisformarenotincludibleinthetotalincomeofanyotherpersonu/s60to64oftheIncometaxAct,1961.*I/Wefurther, declarethatthetax*onmy/ourestimatedtotalincome,including*income/incomesreferredtoinColumn22above,computedinaccordancewiththeprovisions oftheIncometaxAct,1961,forthepreviousyearendingon....................relevanttotheassessmentyear..................willbenil.*I/Wealso,declarethat*my/our *income/incomesreferredtoinColumn22forthepreviousyearendingon....................relevanttotheassessmentyear..................willnotexceedthemaximum amountwhichisnotchargeabletoincometax. Place: Date: .. .. . SignatureoftheDeclarant

PARTII [Forusebythepersontowhomthedeclarationisfurnished] 1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn22ofPartI 2.PANofthepersonindicatedinColumn1ofPartII 3.CompleteAddress 4.TANofthepersonindicatedinColumn1ofPartII 5.Email 8.DateonwhichDeclarationisFurnished (dd/mm/yyyy) 6.TelephoneNo.(withSTDCode)andMobileNo. 9.Periodinrespectofwhichthedividendhasbeen declaredortheincomehasbeenpaid/credited 7.Status 10.Amountofincomepaid
11.Dateonwhichtheincome hasbeenpaid/ credited(dd/mm/yyyy)

12.Dateofdeclaration,distributionorpaymentofdividend/withdrawalunderthe NationalSavingsScheme(dd/mm/yyyy)

13.AccountNumberofNationalSavingSchemefromwhichwithdrawalhas beenmade

ForwardedtotheChiefCommissionerorCommissionerofIncometax

Place: Date:

.. .

Signatureofthepersonresponsiblefor payingtheincomereferredtoin Column22ofPartI

Notes: 1. 2. 3. 4. 5.

Thedeclarationshouldbefurnishedinduplicate. *Deletewhicheverisnotapplicable.
#

Declarationcanbefurnishedbyanindividualundersection197A(1)andaperson(otherthanacompanyorafirm)undersection197A(1A). **IndicatethecapacityinwhichthedeclarationisfurnishedonbehalfofaHUF,AOP,etc. Beforesigningthedeclaration/verification,thedeclarantshouldsatisfyhimselfthattheinformationfurnishedinthisformistrue,correctandcompleteinall respects.Anypersonmakingafalsestatementinthedeclarationshallbeliabletoprosecutionunder277oftheIncometaxAct,1961andonconvictionbe punishable i) Inacasewheretaxsoughttobeevadedexceedstwentyfivelakhrupees,withrigorousimprisonmentwhichshallnotbelessthan6monthsbutwhich mayextendtosevenyearsandwithfine; ii) Inanyothercase,withrigorousimprisonmentwhichshallnotbelessthan3monthsbutwhichmayextendtotwoyearsandwithfine.

6.

Thepersonresponsibleforpayingtheincomereferredtoincolumn22ofPartIshallnotacceptthedeclarationwheretheamountofincomeofthenaturereferred toinsubsection(1)orsubsection(1A)ofsection197Aortheaggregateoftheamountsofsuchincomecreditedorpaidorlikelytobecreditedorpaidduringthe previousyearinwhichsuchincomeistobeincludedexceedsthemaximumamountwhichisnotchargeabletotax.";