PDF Editor: Form No. 15G

FORM NO.
15G
[See section 197A(1C), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A (1A) of the Incometax Act, 1961 to be made by an individual or Person (not being a
company or firm) claiming certain receipts without deduction of tax.
PART - I
1] Name of Assessee (Declareant) :
2] PAN :
3] Assessment Year :
6] Status
4] Flat / Door / Block No. :
5] Name of Premises :
8] Road / Street / Lane :
9] Area / Locality :
11] Town / City / District :
12] State :
15] Email :
13] PIN
16] Telephone / Mobile No :
7] Assessed in which
Ward / Circle :
10] AO Code (whom assessed last time) :
Area Code
AO Type
Range Code
AO No.
14] Last Assessment Year in

which assessed :
17] Present Ward / Circle :
18] Residential Status :
19] Name of Business / Occupation :
20] Present AO Code (if not same as above):
21] Jurisdictional Chief Comm. of Income Tax or Comm. of Income

Tax (if not assessed to income tax earlier):
Area Code
AO Type
Range Code
AO No.
(Please tick the relevant box)

22] Estimated total income from the sources mentioned below:
Dividend from shares referred to in Schedule - I
Interest on securities referred to in Schedule - II
Interest on sums referred to in Schedule - III
Income form units referred to in Schedule - IV
The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
23] Estimated total income of the previous year in income mentioned in Col - 22 to be included :
24] Details of investments in respect of which the declaration is being made :
SCHEDULEI
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
No. of
Class of shares & face
Total value
Distinctive numbers
Date on which the shares were acquired
shares
value of each share
of shares
of the shares
by the declarant (dd/mm/yyyy)
SCHEDULEII
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of
Number of
Amount of
Date(s) of
Date(s) on which the securitues were
securities
securities
securities
securities (dd/mm/yyyy)
acquired by declarant (dd/mm/yyyy)
SCHEDULEIII
(Details of the sums given by the declarant on interest)
TM
Name and address of the person to
Amount of sums
Date on which sums given
Period for which sums
Rate of
whom the sums are given on interest
given on interest
on Interest (dd/mm/yyyy)
were given on interest
interest
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SCHEDULE IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the
Number of
Class of units & face
Distinctive number
Income in
mutual fund
units
value of each unit
of units
respect of units
SCHEDULEV
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account under the
Date on which the account
The amount of withdrawal
National Savings Scheme is maintained and the account number
was opened (dd/mm/yyyy)
from the account
Signature of the Declarant
Declaration / Verification
*I/ We
do hereby declare that to the best of
knowledge and belief what is stated above is correct, complete and truly stated. *I /We declare that incomes
referred to in this form are not includible in the total income of any other person u/s 60 to 64 of Income Tax Act,
1961. *I/We further, declare that tax *on my / our estimated total income, including *income / incomes referred to
in column 22 above, computed in accordance with provisions of the Income Tax Act 1961. for the previous
year ending on
relevant to the relevant to the assessment year
will be nil.
*I / We also, declare that *my / our *income / incomes referred to in Column 22 for the previous year ending
on
relevant to the assessment year
will not exceed the maximum amount
which is not chargeable to income tax.
Place :
Date :
Signature of the Declarant
PART - II
[For use by the person to whom the declaration is furnished]
1] Name of the person responsible for paying the income referred to

in Column 22 of Part I :
2] PAN of the person indicated in Column 1 of

Part II :
3] Complete Address :
4] TAN of the person indicated in

Column 1 of Part II :
5] Email :
6] Telephone / Mobile No :
7] Status :
8] Date on which Declaration is

Furnished (dd/mm/yyyy) :
11] Date on which the

9] Period in respect of which the 10] Amount of income
income has been paid
paid
:
dividend has been declared or the
/ credited
income has been paid / credited :
(dd/mm/yyyy) :
TM
12] Date of declaration, distribution or payment of
dividend/withdrawal under the National Savings
Scheme(dd/mm/yyyy) :
13] Account Number of National Saving Scheme from

which withdrawal has been made :
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Forwarded to the Chief Commissioner or Commissioner of Incometax
Place :
Date :
Signature of the person responsible for paying the

income referred to in Column 21 of Part I

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FORM NO.

4] Flat / Door / Block No. :

8] Road / Street / Lane :

11] Town / City / District :

14] Last Assessment Year in

19] Name of Business / Occupation :

20] Present AO Code (if not same as above):

21] Jurisdictional Chief Comm. of Income Tax or Comm. of Income

(Please tick the relevant box)

Class of shares & face

Date on which the shares were acquired

value of each share

by the declarant (dd/mm/yyyy)

Date(s) on which the securitues were

acquired by declarant (dd/mm/yyyy)

Name and address of the person to

Date on which sums given

Period for which sums

whom the sums are given on interest

were given on interest

Class of units & face

value of each unit

Date on which the account

The amount of withdrawal

National Savings Scheme is maintained and the account number

was opened (dd/mm/yyyy)

from the account

Signature of the Declarant

Signature of the Declarant

1] Name of the person responsible for paying the income referred to

2] PAN of the person indicated in Column 1 of

4] TAN of the person indicated in

8] Date on which Declaration is

11] Date on which the

13] Account Number of National Saving Scheme from

Signature of the person responsible for paying the

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