Sr No in

Form 15G
Sr No in
Form 15H
PARTICULARS (REQUIRED DETAILS)
ANSWERS
Sr No in
Form 15G
Sr No in
Form 15H
FORM NO. 15H
[See section 197A(1C), 197A(1A) and rule 29C(1A)]
Declaration under section 197A(1C) of the Incometax Act, 1961 to be made by an individual who is of the age of sixty years or more claiming certain
receipts without deduction of tax.
PART - I
1] Name of Assessee (Declareant) : 2] PAN :
AGLPN1819M
M NANDHINI
3] Age :
2014-15
4] Assessment Year : Individual
5] Flat / Door / Block No. : 6] Name of Premises :
7] Assessed in which
Ward / Circle :

1/828,
11] Town / City / District : 12] State :

8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (whom assessed last time) :
11TH STREET, KARTHIKEYAPURAM, Area Code AO Type Range Code AO No.
15] Email : 16] Telephone / Mobile No :
17] Present Ward / Circle : WD I(3) TBM
044-22470442
CHENNAI
TAMILNADU 14] Last Assessment Year in
which assessed :

13] PIN 600091
18] Name of Business / Occupation :
19] Present AO Code (if not same as above):
HOUSEWIFE
20] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax (if not
assessed to income tax earlier):
Area Code AO Type Range Code AO No.
CHE W
Interest on securities referred to in Schedule - II X
Interest on sums referred to in Schedule - III
Income form units referred to in Schedule - IV
141
21] Estimated total income from the sources mentioned below: (Please tick the relevant box)
Dividend from shares referred to in Schedule - I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
No. of Class of shares & face Total value Distinctive numbers Date on which the shares were acquired
The amt of withdrawal referred in clause(a) of subsec2 of sec80CCA referred in Schedule V
22] Estimated total income of the previous year in income mentioned in Col - 21 to be included :
23] Details of investments in respect of which the declaration is being made :
SCHEDULEI
shares value of each share of shares of the shares by the declarant (dd/mm/yyyy)

(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Amount of Date(s) of Date(s) on which the securitues were

SCHEDULEII
securities securities securities securities (dd/mm/yyyy) acquired by declarant (dd/mm/yyyy)
FIXED DEPOSIT ONE Rs.1,30,000.00 02.02.2013 02.02.2008
(Details of the sums given by the declarant on interest)
Name and address of the person to Amount of sums Date on which sums given Period for which sums Rate of
SCHEDULEIII

NIL NIL NIL NIL

whom the sums are given on interest given on interest on Interest (dd/mm/yyyy) were given on interest interest
V
on relevant to the relevant to the assessment year will be nil.
V
Forwarded to the Chief Commissioner or Commissioner of Incometax
SCHEDULE IV (Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the Number of Class of units & face Distinctive number Income in
mutual fund units value of each unit of units respect of units

SCHEDULEV (Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account under the Date on which the account The amount of withdrawal
National Savings Scheme is maintained and the account number was opened (dd/mm/yyyy) from the account
NIL
Signature of the Declarant
Declaration / Verification
*I/ We M NANDHINI do hereby declare that I am resident in India within

NIL
Date : 16-May-2014 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 21 of Part I
:
2] PAN of the person indicated in Column 1 of Part II :
meaning of section 6 of the Incometax Act, 1961. I also, hereby declare that to the best of my knowledge and belief what is stated
above is correct, complete and is truly stated and 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 further, declare that the tax my estimated total income, including
*income / incomes referred to in column 21computed in accordance with the provisions of the Incometax Act, 1961, for the previous
year ending
31/03/2014 2014-15
Place : CHENNAI
MADIPAKKAM, CHENNAI - 600091
5] Email : 6] Telephone / Mobile No : 7] Status :
BANK OF INDIA
3] Complete Address : 4] TAN of the person indicated in
VASAN COMPLEX,, BALIAH GARDENS. Column 1 of Part II :
Manager
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) :
Rs. 11,618/-
16-May-2014
Place : CHENNAI Signature of the person responsible for paying the
Date : income referred to in Column 21 of Part I
Rs.967.73 per month
12] Date of declaration, distribution or payment of dividend/withdrawal
under the NSS (dd/mm/yyyy) :
13] Account Number of NSS from which withdrawal has been made :


FORM NO. 15G
[See section 197A(1C), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A (1A) of the Incometax Act, 1961 to be made by an individual or Person (not being a company or firm)
claiming certain receipts without deduction of tax.
PART - I
1] Name of Assessee (Declareant) : 2] PAN :
AGLPN1819M
M NANDHINI
3] Assessment Year :
2014-15
6] Status Individual
4] Flat / Door / Block No. : 5] Name of Premises :
7] Assessed in which Ward
/ Circle :

1/828,
11] Town / City / District : 12] State :

8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (whom assessed last time) :
11TH STREET, KARTHIKEYAPURAM, Area Code AO Type Range Code AO No.
15] Email : 16] Telephone / Mobile No : 17] Present Ward / Circle : WD I(3) TBM
044-22470442 18] Residential Status : Resident
CHENNAI
TAMILNADU 14] Last Assessment Year in which
assessed :

13] PIN 600091
19] Name of Business / Occupation :
20] Present AO Code (if not same as above):
HOUSEWIFE
21] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax (if not
assessed to income tax earlier):
Area Code AO Type Range Code AO No.
CHE W
Interest on securities referred to in Schedule - II X
Interest on sums referred to in Schedule - III
Income form units referred to in Schedule - IV
141 3
22] Estimated total income from the sources mentioned below:
Dividend from shares referred to in Schedule - I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
No. of Class of shares & face Total value Distinctive numbers Date on which the shares were acquired
The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
23] Estimated total income of the previous year in income mentioned in Col - 22 to be included :
24] Details of investments in respect of which the declaration is being made :
SCHEDULEI
shares value of each share of shares of the shares by the declarant (dd/mm/yyyy)

(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Amount of Date(s) of Date(s) on which the securitues were

SCHEDULEII
securities securities securities securities (dd/mm/yyyy) acquired by declarant (dd/mm/yyyy)
FIXED DEPOSIT ONE Rs.1,30,000.00 02.02.2013 02.02.2008
(Details of the sums given by the declarant on interest)
Name and address of the person to Amount of sums Date on which sums given Period for which sums Rate of
A/C805642710000006
SCHEDULEIII
NIL
whom the sums are given on interest given on interest on Interest (dd/mm/yyyy) were given on interest interest
NIL NIL NIL



V
for the previous year ending on relevant to the assessment year will be nil.
relevant to the assessment year will not exceed the maximum amount which is not chargeable to income tax.
V
Forwarded to the Chief Commissioner or Commissioner of Incometax ____________________
SCHEDULE IV (Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the Number of Class of units & face Distinctive number Income in
mutual fund units value of each unit of units respect of units

Particulars of the Post Office where the account under the Date on which the account Amount of withdrawals
National Savings Scheme is maintained and the account number was opened (dd/mm/yyyy) from the account
SCHEDULEV (Details of the withdrawal made from National Savings Scheme)
NIL
Signature of the Declarant
Declaration / Verification
*I/ We
M NANDHINI
do hereby declare that to the best of knowledge

NIL
Place : CHENNAI
Date : 16-May-2014 Signature of the Declarant
and belief what is stated above is correct, complete and truly stated. *I /We declare that incomes referred to in this form are not includible
in the total income of any other person u/s 60 to 64 of Income Tax Act, 1961. *I/We further, declare that tax *on my / our estimated total
income, including *income/incomes referred to in column 22 above, computed in accordance with provisions of the Income Tax Act 1961,
31/03/2014 2014-15
31/03/2014
2014-15
*I / We also, declare that *my / our *income / incomes referred to in Column 22 for the previous year ending on
3] Complete Address : 4] TAN of the person indicated in
VASAN COMPLEX,, BALIAH GARDENS. Column 1 of Part II :
MADIPAKKAM, CHENNAI 600091
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 :
BANK OF INDIA
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) :
Rs. 11,618/-
16-May-2014 Rs.967.73 per month
5] Email : 6] Telephone / Mobile No : 7] Status :
Manager
Place : CHENNAI Signature of the person responsible for paying the
Date : income referred to in Column 21 of Part I
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 :