FORM NO.15G [See section 197A(1), 197A(A) and rule 29CI Declaration under section 197A(1) and section 197A(1A) of the Income-tax Act, 1961 to be made by an cee ara aa sa tnot being # company or firm) claiming certain receipts without deduction of tax. ” PART -I T Name of Ansosocs(beclaranb TaN ee Ny Asse PAN CARD No - &mp: Name aamatte fg Fat Door Blok No. Name of Frees {teil bnyeete_2.016~ 2017 _ tates __TWOTVIDUAL Emp - Ada - Emp: Add 7 Posed whieh Word Cie Road / Svea [Lane a Aveo" Tosa Hind Gnieeaier shen I ae acened ast tine) Ti. Town | Giy / District 12, State ae [ae eae | ne oe ys TPN _ 8 Tat Avena Year 5 = 2000 | ich macseed 15 Baal TE Fipin Wo BO Gi tie No |W seaweed —— 9876543210 Ti Radon Satan ib 19; Name of Business 7 Occupation Fst etabieleniallltesaad Fa Pat AD Ga ia oe oe ai Janladisiooal Chet Commissioner of Incometax or Commissioner of | Ame | AO] Rag | 00 Income-tax (if not assessed to Income-tax earlier) Lote _| Trpe |_Code Be 2 1 [22 Feaiaed Tt Taso om tho sonia mentioned olow . roan a loa ak Didead rom shares erred won Schedsle |B Trica on soar Toterred to To Schedsle |B z Tiana on sma referred to In Schedule |B Tess fom nie tired to fn Sbedule TV | &h Fea AR in SCENE ro Rar Sis Sm rl w Sa |e Sai alan prov ern ih core nel in Cl i nda 124: Details of investments in respect of which the declaration is being made : SCHEDULE - 1 (Details of shares, which stand in the name of the declarant and beneficially owned by him) (clans of shares & fac Total value ‘atta op Which he dhs wore value of each share | _of shares acqoird by the delarant cmmyy30) SCHEDULE - II (Detaile of the securities held in the name of declarant and beneficially owned by bir) Taasription of | Namber of | Amount of [Datei of Securities | Dale on which the seceilios were "eeuritics seca | ‘aecurition | —tadlmmayyyy)—_|actlted by the deslarant (6dmmlyyry we SCHEDULE - TIT (Derails of the sums given by the declarant on interest) ame aad dire ofthe patron to who] Amount of aura] Deon whi ie uma were [Period for whieh wun] Fate of given on Interest pene interest iy | wer geen x interest|ntatest | :SCHEDULE - IV {Desais of toe maton fund unis eld inthe name of dslarant and boneiilly owned by him) o TNonmber | Cha o goit & fae [Dislinctive wana] Tasgue er en ea oh Pit’ SCHEDULE - V (Details of the withdrawal made from National Savings Scheme) Tartclars of We Pot Oice where te goons under he [Date on which the aceount|'The amioant of withdrawal ‘tonal Savings Scheme i mintaned and the account number] was openedidd/mm/yyye) | from the account pir Simp. Sian - TY Shar the deslarand Declaration / Verification “teu. Employee... Name, : wee do hereby declare that to the best of ty / our knomlage and belief what i tated above ia correct, complete and is truly stated, °1/ We declate that the incomes referred tn thie form are not include in the ttl income of any other person ws Bd to Gof the Inenme-tax Act, 196 *1/We further, declare that the tax fom my / our estimated total income, including tncome J incomes referred to in Column 22 above, computed in accordance with the provisions ofthe lnomedax Act, 1961, forthe previous year ending on 31.037 2016, relorant to she astorment year 20162, 2017, Wel be nik *1/ We also, declare that *my eur ‘income / incomes referred to in Column 22 for the previous year ending on ..31703 7.20.16, relevant 10 the assessment year 2.016.207... wit nt exceed the mainte amount which aot changeable to income. Pac: : < mp: Sfen: pia Sign of A delarant PART - 1 [For use by the person to whom the declnration is furnished) 1. Name of the person responsible for paying the income refered to in Column 22 of Part T]2 PAN of the person indicated in Calum 1 of Purt I 5. Complote Address TAN of the person indicated in Column 1 of Part IT 5. Emil 6 Telephone No, (with STD Code and Maile Na. [7 Status Date on wich Deslration te Peal i wet of Wich ie Gilead is baw [IO Arson of [UTD om Te Furnished (ddimmiyyyy) dlr arth income has ben paid cmcited | income paid jinn ap Seen, paid Ta, Date of declaration, distrition or payment of dividend /—[ 15, Account Number of National Saving Scheme Wom Which ‘withdrawal under the National Savinga Scheme (dilimmiyyyy) | withdrawal haa beon made Forwarded to the Chief Commissioner ur Commissioner of fncome-tax Signature of the person responsible for paying the income referred to in Cobumn 22 of Part | 2 rgeiey,tan «cma Fm nde sete AACA SOT PS omar no ere om fa mes hte in hte ea nt ng ata en ‘TAX PRINT, 177, Parin Nariman (Sazargate) Steet, Fort, Mumbai - 400 001, @ Phones : 4347 0909 / 2260 $921 © 2269 5676