FORM NO.

15H
[See rule 29C(3)]
Declaration under section 197A(1A) of the income-tax Act, 1961, to be mae
b! a "e#son (not bein$ a com"an! o# fi#m) c%aimin$ #ecei"t of inte#est othe# than &'nte#est
on sec(#ities) o# income in #es"ect of (nits *itho(t e(ction of tax
+a#t '
*I/we,
---------------------------------------------------------------------------------------------------------------------son/daughter/wife
of -------------------------------------------------------------------------------------------------resident of
------------------------------------------------------------------------------- @ do hereby declare -
1. that the sums, particulars of which are given below, stand in *my/our name and beneficially belong to
*me/us, and the *interest in respect of such sums and/or income in respect of units is/are not includible
in the total income of any other person under sections 6 to 6! of the Income-ta" #ct, 1$61 %
,ab%e '
Name an a#ess of the
"e#son to *hom the s(ms
a#e $i-en on inte#est
Amo(nt of
s(ch s(ms
.ate on *hich s(ms
*e#e $i-en on
inte#est
+e#io fo# *hich
s(ch s(ms *e#e
$i-en on inte#est
Rate of inte#est
,ab%e ''
Name an a#ess of the M(t(a% F(n N(mbe# of (nits /%ass of (nits
an face -a%(e
of each (nit
.istincti-e
n(mbe# of
(nits
'ncome in
#es"ect of
(nits
&. that *my/our present occupation is % ,
'. that the ta" on *my/our estimated total income including the *interest other than (interest on securities)
and/or income in respect of units, referred to in paragraph 1 computed in accordance with the
provisions of the income-ta" #ct, 1$61, for the previous year ending on relevant to the
assessment year 1$ 1$ , will be nil*
!. that *I/we have not been assessed to Income-ta" at any time in the past, but *I/we fall within the
+urisdiction of the ,hief ,ommissioner of Income-ta" , -.
that *I/we *was/were last assessed to Income-ta" for the assessment year 1$---------1$--------- by the
#ssessing -fficer ,ircle//ard/0istrict and the permanent account number allotted
to *me/us is .
-------------------------------
**1ignature of declarant
0e#ification
*I/we do hereby declare that the contents of the paragraph 1
to ! are true to the best of *my/our 2nowledge and belief and nothing has been concealed therein.
3erified today, the day of 1$ .
4lace --------------------------------
1ignature of declarant
+a#t ''
1Fo# (se b! the "e#son to *hom the ec%a#ation is f(#nishe2
FOR 345 67 ,H5 +5R4ON ,O 8HOM ,H5 .5/9ARA,'ON '4 F3RN'4H5.)
1. 5ame and address of the person responsible
for paying interest on sums or income in respect
of units, as the case may be, mentioned in
paragraph 1 of the declaration
&. 0ate on which the declaration was furnished by
the declarant
'. 4eriod for which interest or income in respect of
units as the case may be is credited/paid.
!. #mount of interest or income in respect of units
as the case may be
6. .ate at which interest or income in respect of
units as the case may be is credited/paid
7orward to the ,hief ,ommissioner of Income-ta"
4lace
0ate
---------------------------------------------------------------------------
1ignature of the person responsible for paying interest
other than interest on securities/income in respect of units
5otes %
1. @ 8ive complete postal address.
&. 9he declaration should be furnished in duplicate.
'. *0elete whichever is not applicable.
!. **indicate the capacity in which declaration is furnished to behalf of a :indu undivided family, association of persons
etc.
6. ;efore signing the verification, the declarant should satisfy himself that the information furnished in the declaration is
true, correct and complete in all respects.
6. #ny person ma2ing a false statement in the declaration shall be liable to prosecution under section &<< of the
Income-ta" #ct, 1$61, and on conviction be punishable -
i. in a case where ta", which would have been evaded if the statement or account had been accepted as true
e"ceeds one hundred thousand rupees, with rigorous imprisonment for a term which shall not be less than si"
months but which may e"tend to seven years and with fine*
ii. in any case, with rigorous imprisonment which shall not be less than three months but which may e"tend to three
years and with fine.