FC,R,M hIO.

15 G

{See seetion 19?A(1), 197A(lA) o,nd, rule 29C}

Oeclaration under section lS?A(l) and section 19?A(IA) of the Ineome.tax Act, 1961 to be made by an
individual or a person (not being o company or firm) claiming certain receipts without deduction of tax.
PART . I
1. Name ol'Assessee {Doclarant)

?. PAN ofthe

4. FIat / Iloor I lllock No.

ir. Name

3. Assessment Year
I tbr rvhich rlcclarstjon i* bcing nradrt
6. *Status

8. Road I Street / Lane

9. Area

Assessee

tf

Prenrises

/ Circle
AO Code{under whom

7. :lssessed in which \Yard

/ Locality

1.0.

assessed
11..

Town

CiLy

/ District

Area

12. Siate
13. PIN

1,1.

15. Ernail

last time)
AO

Range

AO

Last Assessment Year in

lvhich assessed

elcPtrurrtr

1?. Present Ward / Circle

1$. llesitlential Status {rvithin thc

19. Name of Business

meaning of Section 6 of the lncome.-Tar

Act,1961)

Occupation

20. Present A0 Code (if not snme as above)

21. Jurisdictional Chief Commissioner of lrrcome-tax or ('llommissioner of

Income-tax {if not assessed to Income-tax earlier}

22. lstimated total income from the

sour'(es mentioned below

Area

AO

Coda

Range

AO

Code

No.

(Piease tiek the relevant box)

Dirriilend from shares rctbrred to in Sehedule I

Interest on semritie$ referled to in Schedule II
Interest on Burn$ refered to in Schedule III
Income form units referred io in $chedule tV
The amount of withdmw&l rcfrrrcd to in smtion 8fi:CAr2{a) finm Natirxul Savings Schenre referrcd tn
23. Dstimated iotal income of the prrrious year

94. fJetailg nf investments

in

in whidr

incon"re mentioned

respect of rvhich the declaration is being made

SCHIIDT.ILE

in

.I

(Details of shares, which stand in the name of the declarant and treneficially orvnt:d by hirn)
Distinctive uuml:ers
Date(s) iin \vhiclt'the shar:es
0lass of ehaiea & f
of the shares
value bf ebch sh*re

SCHEDULD . II
fletails gf the *eiurities held in the name of declarant and beneficially
I)pscription
sccurities

ol'

Number of
securitics

Arr:ount of
scc

nrities

SCHEDULE

. III

{Detail.s eif the sums given b.y the declarant on interest)

anre and addrss; of the pcrson t$

the eums'are given on interest

ScheduleY

in Column 2t is to be included

owned try him)

were

n
n
n

SCHEDULE - IY

SCHEDULE - V

(Detailg of the withdrawal mado from National IJa

Sclreme)

\
--x-Declaration / Yerifrcation
*

Signature of lhe dcclarant

declare that in the hest of *my 1 our knowledge and beliefwhat is stated above is correct, complete and is truly stated. *I / 1,[e declare that
the incomes refemed to in this form are not includible in the total income of any other person u/e 60 to M of the Income-tsx Act, 1961.

*I /

We further, declare

computed

in

that the tar *on my / our estimated total income, including tincome r' incomes referred to in Column 22 above,

accordance rvith

the provisions of the Income-tax Act, 1961, for tlre previous year ending on ...................
will tre nil. *I / We also. declare thnt *my / our *ineome
....,.,.....

relevant to trhe asaessment yar

referred to
year

in

Column 22 for the previous year ending on ............."..... ..........

,....,.,.....,..

will aot

exceed the maximum amount which

......

relevant to the asses*ment

'

-Date : ___
l.

the

Name of thr; person responsible for paying the ineome

incomes

is not chargeable to income-tax.

Place l

For use

xSignature of

the declarant

PA1BT.II

to whom the declaration is fuurished

rel'errecl to in Column 22 of Part I 2. PAN of the pereon

indicated in Column

of Part

4. 'l'AN of the person indicated in Column

8. Complete Address

5. Email

6. Telephone No. (wit"h

8. Date on which Declaration is

Furnished (dd1mm/yyyy)

9. Period in regpeci ofwhieh the dividend has been

declarrd or the inmme hos b..sn paid / creditsd

$ID

LZ. Dale ol declaratron. dlstribuuon or Davment of dividend i

withdrawal under the National Savingd S<:heme (ddlmm/.vyyy)

Code) and Mobile No.

of Part

II

7. Slatus
10. Amount

of

income paid

11. Date on which the

income hns been paid/

eredited (dd/mrn/iyyy)

l3..Account-Nuqrber of N-ational Sar.ing $cheme from whicf

withdrawal has been made

Forwarded to the Chief Corxrnissioncr or Cournrissioner of Incoms-ttrx

Noter

l. 'Itc

Signature of'the pe.rson responsible for paying the

in.catne referretl to in aolunm 22 of Part I
r

dclrretioo rhould bs fornished

;frtJti,'
i.5: t56i;,;fi;;L-ii;;;.iffi';;uii
i'r'iiii*;;;#"6i;;frt".

a.

iu duolicf,E.

indivirturt under sq.rion l97A(l).tnd a jar.son iorher rhun

or s
--- o- mmpany
-"lndicslx thc crpacity in whicli tlre dcclaratioa ts furnirhed or Ueiialt ofiliijf'. ^lOi. _

,jm)

utrdcr srctiof, loTA(rA).

"t

to &v.n yeu.a arrd Bith lrrre:

coec, with rigrreur
rigrreus. imprixonnent
inptisonnleot-thich
which rhall
strall not
uot he
l* ksa
lesa thsn
thsrr 3 &onths
rtroothr but
but whith
shirh msv
oxriard to tva
rw.] yerrs
vo'ra anrl
rnrt with
uith fine.
Gnmsy extrrrrl

iir Itr
In eoy
noy othcr
--. ii)
- .-.

whic.b ruch inamo is

II

t! br inrluded excoeas tle muifrfim""mo,iiriittilJii x';;;ffi;;:6k;;il:'

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