"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.
8. Road/Street/Lane
15. Email
18. Name of Business/Occupation
20. Jurisdictional Chief Commissioner of Income‐tax or Commissioner of Income‐tax
(if not assessed to Income‐tax earlier)
11. Town/City/District
6. Name of Premises
9. Area/Locality
16. Telephone No. (with STD Code)
and Mobile No.
12. State
13. PIN
14. Last Assessment Year in which assessed
10. AO Code
(under whom assessed last time)
17. Present Ward/Circle
19. Present AO Code (if not same as above)
7. Assessed in which Ward/Circle
Area Code AO Type Range Code AO No.
Area Code AO Type Range Code AO No.
21. Estimated total income from the sources mentioned below:
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:
(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 form 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
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)
No. of shares
Description of securities
Name and address of the person to whom the sums are given on interest
Name and address of the mutual fund
Amount of sums given on interest
Number of units
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)
Number of securities Amount of securities Date(s) of securities (dd/mm/yyyy)
Date on which the sums were given on interest (dd/mm/yyyy)
Class of units and face value of each unit
Date(s) on which the securities were acquired by the declarant (dd/mm/yyyy)
Period for which such sums were given on interest
Distinctive number of units
Rate of interest
Income in respect of units
SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
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
Signature of the Declarant
Date:___________________ Signature of the Declarant
Place:___________________
Date:___________________
Place:___________________
Declaration/Verification
I___________________________________________do hereby declare that I am resident in India within the meaning of section 6 of the Income‐tax Act, 1961.
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.
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,
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
5. Email
8. Date on which Declaration is Furnished (dd/mm/yyyy)
7. Status
10. Amount of income paid 11. Date on which the income
has been paid/credited (dd/mm/yyyy)
6. Telephone No. (with STD Code) and Mobile No.
9. Period in respect of which the dividend has been declared or the income has been paid/credited
4. TAN of the person indicated in Column 1 of Part II
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
Forwarded to the Chief Commissioner or Commissioner of Income‐tax____________________________________________
Signature of the person responsible for
paying the income referred to in
Column 21 of Part I
Notes:
1. The declaration should be furnished in duplicate.
2. *Delete whichever is not applicable.
3. 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
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
i) 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;
ii) 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.
IDBI Bank Limited, Regd. Office: IDBI Tower, WTC Complex, Cuffe Parade, Mumbai – 400 005.
Toll Free Numbers reachable from any landline/Mobile phones: 1800-200-1947 / 1800-22-1070, Non - Toll Free Number: 022-66937000. Website: www.idbi.com
be punishable -
which the declarant is eligible.