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11.Town/City/District
12.State 13.PIN 14.LastAssessmentYearinwhich assessed 17.PresentWard/Circle 18.ResidentialStatus(withinthe meaningofSection6oftheIncomeTax Act,1961) 20.PresentAOCode(ifnotsameas above)
AreaCode AOType RangeCode AONo.
15.Email 19.NameofBusiness/Occupation
16.TelephoneNo.(withSTDCode)andMobileNo.
(Pleaseticktherelevantbox) DividendfromsharesreferredtoinScheduleI InterestonsecuritiesreferredtoinScheduleII InterestonsumsreferredtoinScheduleIII IncomeformunitsreferredtoinScheduleIV Theamountofwithdrawalreferredtoinsection80CCA(2)(a)fromNationalSavingsSchemereferredtoinScheduleV 23.EstimatedtotalincomeofthepreviousyearinwhichincomementionedinColumn22istobeincluded 24.Detailsofinvestmentsinrespectofwhichthedeclarationisbeingmade: SCHEDULEI (Detailsofshares,whichstandinthenameofthedeclarantandbeneficiallyownedbyhim) No.of Classofshares& Totalvalue shares Distinctivenumbersoftheshares facevalueofeach Date(s)onwhichtheshareswereacquiredbythe ofshares share declarant(dd/mm/yyyy)
Descriptionof securities
SCHEDULEIII (Detailsofthesumsgivenbythedeclarantoninterest) Nameandaddressofthe Amountof persontowhomthesumsare sumsgiven givenoninterest oninterest Dateonwhichthesumsweregivenon interest(dd/mm/yyyy) Periodforwhichsumswere givenoninterest Rateof interest
SCHEDULEIV (Detailsofthemutualfundunitsheldinthenameofdeclarantandbeneficiallyownedbyhim) Nameandaddressofthe Incomeinrespectof Numberof Classofunitsandfacevalueofeach Distinctivenumberofunits mutualfund unit units units
. **SignatureoftheDeclarant Declaration/Verification
PARTII [Forusebythepersontowhomthedeclarationisfurnished] 1.NameofthepersonresponsibleforpayingtheincomereferredtoinColumn22ofPartI 2.PANofthepersonindicatedinColumn1ofPartII 3.CompleteAddress 4.TANofthepersonindicatedinColumn1ofPartII 5.Email 8.DateonwhichDeclarationisFurnished (dd/mm/yyyy) 6.TelephoneNo.(withSTDCode)andMobileNo. 9.Periodinrespectofwhichthedividendhasbeen declaredortheincomehasbeenpaid/credited 7.Status 10.Amountofincomepaid
11.Dateonwhichtheincome hasbeenpaid/ credited(dd/mm/yyyy)
12.Dateofdeclaration,distributionorpaymentofdividend/withdrawalunderthe NationalSavingsScheme(dd/mm/yyyy)
13.AccountNumberofNationalSavingSchemefromwhichwithdrawalhas beenmade
ForwardedtotheChiefCommissionerorCommissionerofIncometax
Place: Date:
.. .
Notes: 1. 2. 3. 4. 5.
Thedeclarationshouldbefurnishedinduplicate. *Deletewhicheverisnotapplicable.
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