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    Form No.15g

    Uploaded by

    Prakash Gowda
    1. This document contains a declaration form under Section 197A(1) and 197A(1A) of the Indian Income Tax Act of 1961 for an individual to declare certain receipts without deduction of tax. 2. The form collects information about the declarant such as name, PAN, address, estimated total income and details of investments that yield the income being declared such as dividends from shares, interest from securities or deposits, and withdrawals from national savings schemes. 3. By signing the declaration, the individual confirms that the incomes reported are not taxable for any other person and that the estimated tax on their total income for the year will be nil. They undertake that the income being declared will not

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form No.15g

    Uploaded by

    Prakash Gowda
    101 views2 pages
    1. This document contains a declaration form under Section 197A(1) and 197A(1A) of the Indian Income Tax Act of 1961 for an individual to declare certain receipts without deduction of tax. 2. The form collects information about the declarant such as name, PAN, address, estimated total income and details of investments that yield the income being declared such as dividends from shares, interest from securities or deposits, and withdrawals from national savings schemes. 3. By signing the declaration, the individual confirms that the incomes reported are not taxable for any other person and that the estimated tax on their total income for the year will be nil. They undertake that the income being declared will not

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    Original Title

    FORM NO.15G

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    1. This document contains a declaration form under Section 197A(1) and 197A(1A) of the Indian Income Tax Act of 1961 for an individual to declare certain receipts without deduction of tax. 2. The form collects information about the declarant such as name, PAN, address, estimated total income and details of investments that yield the income being declared such as dividends from shares, interest from securities or deposits, and withdrawals from national savings schemes. 3. By signing the declaration, the individual confirms that the incomes reported are not taxable for any other person and that the estimated tax on their total income for the year will be nil. They undertake that the income being declared will not

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    101 views2 pages

    Form No.15g

    Uploaded by

    Prakash Gowda
    1. This document contains a declaration form under Section 197A(1) and 197A(1A) of the Indian Income Tax Act of 1961 for an individual to declare certain receipts without deduction of tax. 2. The form collects information about the declarant such as name, PAN, address, estimated total income and details of investments that yield the income being declared such as dividends from shares, interest from securities or deposits, and withdrawals from national savings schemes. 3. By signing the declaration, the individual confirms that the incomes reported are not taxable for any other person and that the estimated tax on their total income for the year will be nil. They undertake that the income being declared will not

    Copyright:

    © All Rights Reserved
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    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:'

    TAXPRINT, 177,Pailn Narimari(Bazargate) Street,Fort,Mumbai ,400001 .lphones:43470909 /22693321 |}22695676

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