FORM NO. 15G
[See section 197A(1), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A(1A) of the Income‐tax Act, 1961 to be made by an individual or a person (not being a company or firm)
claiming certain receipts without deduction of tax
PART I

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 sums
were given on interest
Rate of
interest
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)
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)
NA NA NA NA NA
FORM NO. 15G
[See section 197A(1), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A(1A) of the Income‐tax Act, 1961 to be made by an individual or a person (not being a company or firm)
claiming certain receipts without deduction of tax.
PART I
1. Name of Assessee (Declarant) 2. PAN of the Assessee
3. Assessment Year
( for which declaration is being made)
4. Flat/Door/Block No. 5. Name of Premises 6. Status
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. Residential Status ( within the
meaning of Section 6 of the Income
Tax Act,1961)
19. Name of Business/Occupation
20. Present AO Code
(if not same as above)
21. Jurisdictional Chief Commissioner of Income‐tax or Commissioner of Incometax
(if not assessed to Income‐tax earlier)
Area Code AO Type Range
Code
AO No.
22. 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 form units referred to in Schedule IV
The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred to in Schedule V
23. Estimated total income of the previous year in which income mentioned in Column 22 is to be included
24. 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
.......................................................................
Signature of the Declarant
SCHEDULE‐V
(Details of the withdrawal made from National Savings Scheme)
Declaration / Verification
I/We…….................................................................................................…………………………do hereby declare that to the best
of my/our knowledge and belief what is stated above is correct, complete and is truly stated. I/We declare 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/We further, declare that the tax on my/our estimated total income, including income/incomes referred to in
Column 22 above, 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/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 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 ividend 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 Saving Scheme from which withdrawal has been made
Place:
Date:
……………………………….......
……………................................ …………………………………………....................
Signature of the person responsible for
paying the income referred to in Column
Notes: 22 of Part I
1. The declaration should be furnished in duplicate.
2. Delete whichever is not applicable.
3.Declaration ca n be furnished by an individual under section 197 A(1) and a person (other than a company or a firm) under section
197 A(1A).
4. Indicate the capacity in which the declaration is furnished on behalf of a H U F, AO P, etc .
5. Before signing the declaration/verification , the declarant should satisfy himself that the information furnished in this form is true,
correct and complete in all respects. Any person making a false statement in the declaration shall be liable to prosecution under 277 of the Income‐tax Act, 1961 and on conviction be punishable)
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.
6. The person responsible for paying the income referred to in column 22 of Part I shall not accept the declaration where the amount of income of the nature referred to in sub‐section (1) or sub‐section (1A) of section 197A 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.";
CENTRAL BANK OF INDIA
Forwarded to the Chief Commissioner of Commissioner of Income-Tax.............................................................