FORM NO.

15G
[See section197A (1), 197A (1A) and rule 29C]
Declaration under section197A (1) and section197A (1A) of the Income-ta Act, 19!1 to "e made "# an indi$idual or a %erson (not "ein& a
com%an# or firm) claimin& certain recei%ts 'ithout deduction of ta(
)A*+ I
1( ,ame of Assessee (Declarant) 2( )A, of the Assessee
-( Assessment .ear
( for 'hich declaration is "ein& made)
/( 0lat1Door12loc3 ,o( 4( ,ame of )remises !(
5
Status
7( Assessed in 'hich 6ard 1
Circle
7( *oad1Street18ane 9( Area18ocalit# 19( A: Code(under 'hom
assessed last time)
Area
Code
A:
+#%e
*an&e
Code
A:
,o(
11( +o'n1Cit#1District 12( State
1-( )I, 1/( 8ast Assessment .ear in
'hich assessed
14( ;mail 1!( +ele%hone ,o( ('ith S+D Code) and
<o"ile ,o(
17( )resent 6ard1Circle
17( *esidential Status ('ithin
the meanin& of Section ! of
the Income +a Act,19!1)
19( ,ame of 2usiness1:ccu%ation
29( )resent A: Code (if not
same as a"o$e)
21( =urisdictional Chief Commissioner of Income-ta or Commissioner of
Income-ta (if not assessed to Income-ta earlier)
Area
Code
A:
+#%e
*an&e
Code
A:
,o(
22( ;stimated total income from the sources mentioned "elo'>
()lease tic3 the rele$ant "o)
Di$idend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Income form units referred to in Schedule I?
+he amount of 'ithdra'al referred to in Sec 79CCA(2)(a) from ,ational Sa$in&s Scheme referred to in
Schedule ?
2-( ;stimated total income of the %re$ious #ear in 'hich income mentioned in Column 22 is to "e
included
2/( Details of in$estments in res%ect of 'hich the declaration is "ein& made>
SC@;DA8;-I
(Details of shares, 'hich stand in the name of the declarant and "eneficiall# o'ned "# him)
,o( of
shares
Class of share B face $alue of
each share
+otal $alue of
shares
Distincti$e num"ers
of the shares
Date(s) on 'hich the shares 'ere
acCuired "# the Declarant (dd1mm1####)
SC@;DA8;-II
(Details of the securities held in the name of declarant and "eneficiall# o'ned "# him)
Descri%tion of
Securities
,um"er of
securities
Amount of securities Date(s) of Securities
(dd1mm1####)
Date(s) on 'hich the securities 'ere
acCuired "# the declarant (dd1mm1####)
SC@;DA8;-III
(Details of the sums &i$en "# the declarant on interest)
Name and address of the
person to whom the sums
are given on interest
Amount of
sums given
on interest
Date on which the
sums were given on
interest(dd/mm/yyyy)
Period for which sums
were given on interest
Rate of
Interest
SC@;DA8;-I?
(Details of the mutual fund units held in the name of declarant and "eneficiall# o'ned "# him)
,ame and address of
the mutual fund
,um"er of
units
Class of units and face
$alue of each unit
Distincti$e num"er of units Income in res%ect of units
SC@;DA8;-?
(Details of the 'ithdra'al made from ,ational Sa$in&s Scheme)
)articulars of the )ost : ce 'here the account under the ,ational
Sa$in&s Scheme is maintained and the account num"er
Date on 'hich the account 'as
o%ened (dd1mm1####)
+he Amount of
'ithdra'al from account
DDDDDDDDDDDDDDDDDDDDDDDDDDDD
EE Si&nature of declarant
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Declaration/Verification
EI16e DDDDDDDDDDDDDDDDDDDDDDDDDD DDDD do here"# declare that to the "est of Em#1our 3no'led&e and "elief 'hat is
stated a"o$e is correct, com%lete and is trul# stated( EI16e declare that the incomes referred to in this form are not includi"le in the
total income of an# other %erson u1s !9 to !/ of the Income-ta Act, 19!1( EI16e further, declare that the ta Eon m#1our estimated
total income, includin& Eincome1incomes referred to in Column 22 a"o$e, com%uted in accordance 'ith the %ro$isions of the
Income-ta Act, 19!1, for the %re$ious #ear endin& on DDDDDDDDDD rele$ant to the assessment #ear DDDDDDDDDD 'ill "e nil(
EI16e also, declare that Em#1ourEincome1incomes referred to in Column 22 for the %re$ious #ear endin& on DDDDDDDDDD rele$ant
to the assessment #ear DDDDDDDDDD 'ill not eceed the maimum amount 'hich is not char&ea"le to income-ta(
)lace > DDDDDDDDDD
Date > DDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDDDDDD
EE Si&nature of declarant
PART II
[0or use "# the %erson to 'hom the declaration is furnished]
1( ,ame of the %erson res%onsi"le for %a#in& the income referred to in
Column 22 of )art I
2( )A, of the %erson indicated in Column
1 of )art II
-( Com%lete Address

/( +A, of the %erson indicated in Column 1
of )art II
4( ;mail !( +ele%hone ,o( ('ith S+D Code) and
<o"ile ,o(
7( Status
7(Date on 'hich Declarations
0urnished (dd1mm1####)
9( )eriod in res%ect of 'hich the di$idend
has "een declared or the income has
"een %aid1credited
19( Amount of income
)aid
11( Date on 'hich the
income
has "een %aid1
credited(dd1mm1####)
12( Date of declaration, distri"ution or %a#ment of di$idend 1
'ithdra'al under the ,ational Sa$in&s Scheme
(dd1mm1####)
1-( Account ,um"er of ,ational Sa$in& Scheme from
'hich 'ithdra'al has "een made
0or'arded to the Chief Commissioner or Commissioner of Income-ta DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
)lace > DDDDDDDDDD
Date > DDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
Si&nature of the %erson res%onsi"le for %a#in&
the income referred to in Column 22 of )art I
Notes:
1( +he declaration should "e furnished in du%licate(
2( EDelete 'hiche$er is not a%%lica"le(
-(
5
Declaration can "e furnished "# an indi$idual under section197A (1) and a %erson (other than a com%an# or a firm) under
section197A (1A)(
/( EEIndicate the ca%acit# in 'hich the declaration is furnished on "ehalf of a @A0, A:), etc(
4( 2efore si&nin& the declaration1$erification, the declarant should satisf# himself that the information furnished in this form is
true, correct and com%lete in all res%ects( An# %erson ma3in& a false statement in the declaration shall "e lia"le to %rosecution
under 277 of the Income-ta Act, 19!1 and on con$iction "e %unisha"le-
i) In a case 'here ta sou&ht to "e e$aded eceeds t'ent#-fi$e la3h ru%ees, 'ith ri&orous im%risonment
'hich shall not "e less than ! months "ut 'hich ma# etend to se$en #ears and 'ith fineF
ii) In an# other case, 'ith ri&orous im%risonment 'hich shall not "e less than - months "ut 'hich ma# etend
to t'o #ears and 'ith fine(
!( +he %erson res%onsi"le for %a#in& the income referred to in column 22 of )art I shall not acce%t the declaration 'here the
amount of income of the nature referred to in su"-section (1) or su"-section (1A) of section197A or the a&&re&ate of the
amounts of such income credited or %aid or li3el# to "e credited or %aid durin& the %re$ious #ear in 'hich such income is to "e
included eceeds the maimum amount 'hich is not char&ea"le to ta(GF
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