"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.

5.NameofPremises

8.Road/Street/Lane

9.Area/Locality

11.Town/City/District

12.State

6.#Status
7.AssessedinwhichWard/Circle
10.AOCode(underwhomassessedlast
time)
AreaCode AOType RangeCode

13.PIN
15.Email

16.TelephoneNo.(withSTDCode)andMobileNo.

19.NameofBusiness/Occupation

21.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessedto
Incometaxearlier)
22.Estimatedtotalincomefromthesourcesmentionedbelow:

AONo.

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

AONo.

(Pleaseticktherelevantbox)
DividendfromsharesreferredtoinScheduleI
InterestonsecuritiesreferredtoinScheduleII
InterestonsumsreferredtoinScheduleIII
IncomeformunitsreferredtoinScheduleIV
Theamountofwithdrawalreferredtoinsection80CCA(2)(a)fromNationalSavingsSchemereferredtoinScheduleV
23.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn22istobeincluded
24.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade:
SCHEDULEI
(Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim)
No.of
Classofshares&
Totalvalue
Distinctivenumbersoftheshares
shares
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

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Dateonwhichtheaccount
wasopened(dd/mm/yyyy)

Theamountof
withdrawalfromthe
account

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.
**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]
2.PANofthepersonindicatedinColumn1ofPartII
1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn22ofPartI
3.CompleteAddress
4.TANofthepersonindicatedinColumn1ofPartII
5.Email

6.TelephoneNo.(withSTDCode)andMobileNo.

8.DateonwhichDeclarationisFurnished
(dd/mm/yyyy)

9.Periodinrespectofwhichthedividendhasbeen
declaredortheincomehasbeenpaid/credited

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

7.Status
10.Amountofincomepaid

11.Dateonwhichtheincome
hasbeenpaid/
credited(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.";

Printed from www.incometaxindia.gov.in

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