"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

No. of
shares
Total value
of shares
Amount of securities
Amount of
sums given
on interest
Rate of
interest
Number of
units
SCHEDULE II
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of
securities
Number of securities
Date(s) of
securities
(dd/mm/yyyy)
Date(s) on which the securities were
acquired by the declarant(dd/mm/yyyy)
SCHEDULE III
(Details of the sums given by the declarant on interest)
Name and address of the
person to whom the sums are
given on interest
Date on which the sums were given on
interest(dd/mm/yyyy)
Period for which sums were
given on interest
Income in respect of
units
SCHEDULEIV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
SCHEDULEV
Name and address of the
mutual fund
Class of units and face value of each
unit
Distinctive number of units
The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred to in ScheduleV
Interest on securities referred to in Schedule II
Income form units referred to in Schedule IV
Class of shares &
face value of each
share
Distinctive numbers of the shares
Dividend from shares referred to in Schedule I
17. Present Ward/Circle
20. Present AO Code (if not same as
above)
18. Residential Status ( within the
meaning of Section 6 of the Income Tax
Act,1961)
15. Email
(Please tick the relevant box)
19. Name of Business/Occupation
16. Telephone No. (with STD Code) and Mobile No.
21. Jurisdictional Chief Commissioner of Incometax or Commissioner of Incometax (if not assessed to
Incometax earlier)
AO No.
22. Estimated total income from the sources mentioned below:
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
24. Details of investments in respect of which the declaration is being made:
(Details of the withdrawal made from National Savings Scheme)
AO No.
8. Road/Street/Lane 9. Area/Locality
11. Town/City/District 12. State
14. Last Assessment Year in which
assessed
7. Assessed in which Ward/Circle
Declaration under section 197A(1) and section 197A(1A) of the Incometax Act, 1961 to be made by an individual or a person (not being a company or firm) claiming
certain receipts without deduction of tax.
4. Flat/Door/Block No. 5. Name of Premises 6. Status
23. Estimated total income of the previous year in which income mentioned in Column 22 is to be included
SCHEDULEI
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
Date(s) on which the shares were acquired by the
declarant(dd/mm/yyyy)
2. PAN of the Assessee
3. Assessment Year
( for which declaration is being made)
13. PIN
Interest on sums referred to in Schedule III
Area Code AO Type Range Code
AO Type Range Code
1. Name of Assessee (Declarant)
10. AO Code(under whom assessed last
time)
Area Code
Place:
Date:
Place:
Date:
Notes:
1.
2.
3.
4.
5.
i)
ii)
6.
Signature of the Declarant
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
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)
1. Name of the person responsible for paying the income referred to in Column 22 of Part I
3. Complete Address
……………………………………….
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 Incometax 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 Incometax 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 incometax.
Signature of the Declarant
………………………………………………..
………………………………………………..
……………………………………………….
Signature of the person responsible for
paying the income referred to in
Column 22 of Part I
…………………………………………………
…………………………………………………………….
6. Telephone No. (with STD Code) and Mobile No.
7. Status
The declaration should be furnished in duplicate.
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 Incometax Act, 1961 and on conviction be
punishable
[For use by the person to whom the declaration is furnished]
Delete whichever is not applicable.
Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a firm) under section 197A(1A).
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 subsection (1) or subsection (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.";
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 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.
PART II
2. PAN of the person indicated in Column 1 of Part II
4. TAN of the person indicated in Column 1 of Part II
Forwarded to the Chief Commissioner or Commissioner of Incometax…………………………………………………………
………………………………………………..
5. Email
Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.