8/12/2019 Form 15H

1/2

7.Assessed

in

which

Ward/Circle

No.of

shares

Totalvalue

ofshares

Amountof

securities

Amountof

sumsgiven

oninterest

Rateof

interest

Numberof

units

(DetailsofthewithdrawalmadefromNational SavingsScheme)

RangeCode

8.Road/Street/Lane

13.PIN

Intereston

sums

referred

to

in

Schedule

III

9.Area/Locality

14.LastAssessmentYearinwhichassessed

17.PresentWard/Circle

12.State

3.Age 4.AssessmentYear

(forwhichdeclarationisbeingmade)

1.NameofAssessee(Declarant)

10.AOCode(under whomassessedlast

time)

AreaCode

AONo.

19.PresentAOCode (ifnotsameasabove)

AOType

"FORMNO.15H[Seesection197A(1C)andrule29C(1A)]

PARTI

Declarationundersection197A(1C)oftheIncometaxAct,1961tobemadebyanindividualwhoisoftheageofsixtyyearsormoreclaimingcertainreceipts

withoutdeductionoftax.

5.Flat/Door/Block

No. 6.

Name

of

Premises

2.PANoftheAssessee

18.NameofBusiness/Occupation

15.Email 16.TelephoneNo.(withSTDCode)andMobileNo.

20.JurisdictionalChiefCommissionerofIncometaxorCommissionerofIncometax(ifnotassessed

toIncometaxearlier)

11.Town/City/District

RangeCode AONo.

IncomefromunitsreferredtoinSchedule IV

AOType

AreaCode

21.Estimatedtotalincomefromthesourcesmentionedbelow

DividendfromsharesreferredtoinScheduleI

InterestonsecuritiesreferredtoinScheduleII

(Pleaseticktherelevantbox)

SCHEDULEV

Nameandaddressofthe

persontowhomthesumsare

givenoninterest

SCHEDULEII

ParticularsofthePostOfficewheretheaccountundertheNational

SavingsSchemeismaintainedandtheaccountnumber

Dateonwhichtheaccountwas

opened(dd/mm/yyyy)

Theamountof

withdrawalfromthe

account

Nameandaddressofthe

mutualfund

SCHEDULEIII

(Detailsofthesumsgivenbythe declarantoninterest)

SCHEDULEIV

(Detailsofthemutualfundunitsheldinthenameof declarantandbeneficiallyownedbyhim)

Theamountofwithdrawalreferredtoinclause(a)ofsubsection2ofsection80CCAreferredtoinScheduleV

22.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn21istobeincluded

(Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim)

23.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade:

NumberofsecuritiesDescriptionofsecurities

SCHEDULEI

Date(s)of

securities

(dd/mm/yyyy)

Date(s)on

which

the

securities

were

acquired

by

the

declarant(dd/mm/yyyy)

Classofshares&

facevalueofeach

share

Distinctivenumbersof

theshares

Date(s)onwhichtheshareswereacquiredbythe

declarant(dd/mm/yyyy)

Classofunitsandface

valueofeachunit Distinctivenumberofunits Incomeinrespectof

units

Periodforwhichsuchsumswere

givenoninterest

Dateonwhichthesumswere

givenoninterest(dd/mm/yyyy)

(Detailsofthesecuritiesheldinthenameof declarantandbeneficially ownedbyhim)

8/12/2019 Form 15H

2/2

Place:

Date:

Place:

Date:

Notes:1.2.

3.

i)

ii)

4.

Before signing the verification , the declarant should satisfy himself that the information furnished in the declaration is true, correct and complete in all

respects. Any person making a false statementin the declaration shall be liable to prosecution under 277 of the Incometax Act, 1961 and on conviction be

punishable

[Forusebythepersontowhomthedeclarationisfurnished]

*Deletewhicheverisnotapplicable.

The person responsible for paying the income referred to in column 21 of Part I shall not accept the declaration where the amount of income of the nature

referred to in section 197A(1C) or the aggregate of the amounts of such income credited or paid or likely to be credited or paid during the previous year in

which such income is to be included exceeds the maximum amount which is not chargeable to tax and deduction(s) under Chapter VI A, if any, for which the

declarantiseligible.";

In a case where tax sought to be evaded exceeds twentyfive lakh rupees, with rigorous imprisonment which shall not be less than 6 months but

whichmayextendtosevenyearsandwithfine;

Inanyothercase,withrigorousimprisonment whichshallnotbelessthan3monthsbutwhichmayextendto twoyearsandwithfine.

PARTII2.PANofthepersonindicatedinColumn1ofPartII

4.TANofthepersonindicatedinColumn1ofPartII

ForwardedtotheChiefCommissionerorCommissionerofIncometax

..

5.Email

Thedeclarationshouldbefurnishedinduplicate.

6.TelephoneNo.(withSTDCode)andMobileNo.

7.Status

Declaration/Verification

SignatureoftheDeclarant

..

..

.

Signature of the person responsible for

paying the income referred to in Column

21ofPartI

.

.

3.CompleteAddress

I.do hereby declare that I am resident in India within the meaning of section 6 of the Income tax Act, 1961. I also, hereby declare that to

the best of my knowledge and belief what is stated above is correct, complete and is truly stated and that the incomes referred to in this form are not

includible in the total income of any other person u/s 60 to 64 of the Income tax Act, 1961. I further, declare that the tax on my estimated total income,

including *income/incomes referred to in column 21 computed in accordance with the provisions of the Incometax Act, 1961, for the previous year ending on

....................relevanttotheassessmentyear..................willbenil.

.

SignatureoftheDeclarant

12.Dateofdeclaration,distributionorpaymentof

dividend/withdrawalunder

the

National

Savings

Scheme(dd/mm/yyyy)

13.AccountnumberofNationalSavingsSchemefromwhichwithdrawalhasbeenmade

8.Dateonwhichdeclarationisfurnished

(dd/mm/yyyy)

9.Periodinrespectofwhichthedividendhasbeen

declaredorthe incomehasbeenpaid/credited

10.Amountofincomepaid 11.Dateonwhichthe

incomehasbeenpaid/

credited(dd/mm/yyyy)

1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn21ofPartI