FORM NO. 15H
[See section 197A(1C) and rule 29C(1A)]
Declaration under section 197A(1C) of the Income‐tax Act, 1961 to be made by an individual who is of the age of sixty years or more claiming certain receipts without deduction of tax
PART‐ I
No. of
shares
Class of shares & face
value of each share Total value of shares Distinctive numbers of the shares Date(s) on which the shares were acquired by the
declarant(dd/mm/yyyy)
Description of securities
Number of securities Amount of securities
Date(s) of securities
(dd/mm/yyyy) Date(s) on which the securities were
acquired by the declarant(dd/mm/yyyy)
Name and address of the person to whom the sums
are given on interest
Amount of sums given on
interest
Date on which the sums were
given on interest(dd/mm/yyyy)
Period for which such sums
were given on interest
Rate of
interest
FORM NO. 15H
[See section 197A(1C) and rule 29C(1A)]
Declaration under section 197A(1C) of the Income‐tax Act, 1961 to be made by an individual who is of the age of sixty years or
more claiming certain receipts without deduction of tax.
PART‐ I
1. Name of Assessee (Declarant) 2. PAN of the Assessee
3. Age 4. Assessment Year
(for which declaration is being made)
5. Flat/Door/Block No. 6. Name of Premises 7. Assessed in which Ward/Circle
8. Road/Street/Lane 9. Area/Locality 10. AO Code(under whom assessed last
time)
Area Code AO Type Range Code AO No.
11. Town/City/District 12. State
13. PIN
14. Last Assessment Year in which assessed
15. Email 16. Telephone No. (with STD
Code) and Mobile No.
17. Present Ward/Circle
18. Name of Business/Occupation 19. Present AO Code (if not same as above)
20. Jurisdictional Chief Commissioner of Income‐tax or Commissioner
of Income‐tax(if not assessed to Income‐tax earlier)
Area Code AO Type Range Code AO No.
21. Estimated total income from the sources mentioned below
(Please tick the relevant box)
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 from units referred to in Schedule IV
The amount of withdrawal referred to in clause (a) of sub‐section 2 of section 80CCA referred to in Schedule V
22. Estimated total income of the previous year in which income mentioned in Column 21 is to be included
23.Details of investments in respect of which the declaration is being made:
SCHEDULE‐I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
SCHEDULE‐II
(Details of the securities held in the name of declarant and beneficially owned by him)
SCHEDULE‐III
(Details of the sums given by the declarant on interest)
SCHEDULE‐IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the
mutual fund
Number of units Class of units and face
value of each unit
Distinctive number of units
Income in respect of units
Particulars of the Post Office where the account under the National Savings Scheme
is maintained and the account number
Date on which the account
was opened(dd/mm/yyyy)
The amount of withdrawal from the account
NA NA NA
SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
Declaration/Verification
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 Income‐tax Act, 1961, for the previous year ending on .................... relevant to the assessment year
..................will be nil.
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 21
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 No. (with STD Code) and
Mobile No. 7. Status
8. Date on which declaration is furnished
(dd/mm/yyyy)
9. Period in respect of which the
dividend has been declared or the
income has been paid/credited
10. Amount of
income paid
11. Date on which the income
has been paid /
credited(dd/mm/yyyy)
12. Date of declaration, distribution or
payment of dividend/withdrawal under the
National Savings Scheme(dd/mm/yyyy)
13. Account number of National Savings Scheme from which withdrawal has
been made
Place:
Date:
…………………………………
……………............................. ……………………………………………
Signature of the person responsible for
paying the income referred to in Column
21 of Part I
Notes:
1.
2.
3.
The declaration should be furnished in duplicate.
*Delete whichever is not applicable.
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 Income‐tax Act, 1961 and on conviction be punishablei)
ii)
In a case where tax sought to be evaded exceeds twenty‐five lakh rupees, with rigorous imprisonment which shall not be
less than 6 months but which may extend to seven years and with fine;
In any other case, with rigorous imprisonment which shall not be less than 3 months but which may extend to two years
and with fine.
4. 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 declarant is eligible.";

…………………………………………
Signature of the Declarant

CENTRAL BANK OF INDIA
..............................
Forwarded to the Chief Commissioner of Commissioner of Income-Tax.............................................................