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15G
3] Assessment Year
6] Status :
8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (whom assessed last time) :
Area Range
AO Type AO No.
Code Code
11] Town / City / District : 12] State :
Area Range
AO Type AO No.
21] Jurisdictional Chief Comm. of Income Tax or Comm. of Code Code
Income Tax (if not assessed to income tax earlier):
22] Estimated total income from the sources mentioned below: (Please tick the relevant box)
SCHEDULEI
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
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Class of shares &
No. of Total value Distinctive numbers Date on which the shares were acquired
face
shares value of each share of shares of the shares by the declarant (dd/mm/yyyy)
SCHEDULEII
(Details of the securities held in the name of declarant and beneficially owned by him)
SCHEDULEIII
SCHEDULE IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Class of units & Distinctive
Name and address of the Number of Income in
face number
mutual fund units value of each unit of units respect of units
SCHEDULEV
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x
Declaration / Verification
PART - II
Column 1 of Part II :
12] Date of declaration, distribution or payment of 13] Account Number of National Saving Scheme from which
dividend/withdrawal under the National Savings withdrawal has been made :
Scheme(dd/mm/yyyy) :
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Date : income referred to in Column 21 of Part I
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