~ <'i.

/Mobile Number
~

<i<WT/Ciam 1.0 .

ill~ 'lf<M"-11'!R! "!1)111'11, 1952

EMPLOYEES' PROV!NDENT FUND SCHEME. 1952

l!'rn-19/ Form -19
lQ: q;rf ~ f.!Rl "q;T <:l1ll
~ <n>hnfl 1f~>!l AA 'flll<R ~ '~l~Ri!> ~-<:~ &HI ""' VIT11
From to be used by major member of the Employees Provident Fund Scheme, 1952 for claiming the
Provident Fund dues [Par~72] (5)]
~ ..'ffi it '1@ t=roTt <!iT 'it /(Read thc~ng up thi~ for

1
\

~ <liT 'IJl1 ~ 3lffi'! ~

Name of the member (in block letters)

l'l<rrl lffi1' <liT "'IT'1 _ ~ 'ltiffirolt or. 'lT'ffi l'll

Father's! husband's Name in the case of married
women

1 2/
\ I/

~.~~ lilT 'IJl1 lf '1m R;rnq ~ ~

fllu!r 11m "'T /Name and Address of

3.

<lR ~

4.

the Factory /Establishment in which the member

wns last cmEIQYed.
mm 'fl./ Account No.

5.

~ ~ ~ ~/Date oflcuving Service

6.

~~<liT

I 7/

tP-1 ~ lilT

ll?RUIIRcason of leaving Service

'k'T 1f<1T

\_r;r- Full postal address (in block letters)

~ ~ ~llfi'rl~l Shri/Smt.!Kumari ..................... ..... .............. .

~.r.rvq-M\1~ /

S/o/W/o/D/o ............................ ................ ..... ... .. ......... ................ .

!f>re ..

........... .... .. ............ ............................. ............. !'in No.lfiR

:pmR ~

\[)/

liitl)<f ~~

F<lfQ I Mode of Remittance

lf<J; <Rl<ll 'R

if>~ tj

tG<!i ~

Put a 'Tick' in Box against the one opted

(lfl') 11~ mf <R >A'J3llt< lrnl/ (a) By Postal Money
{

Odcr at my cost.

(~~ ) ~ ~i'! 11>--ffi ~ 1)~ W<l m<ll ~-(~

~I <JTi!itH)

mm

i1 'Wif.lm -4i!i ~~-q;-

M lfvn V!T<;/

( )

'IJUil! ~ ~

~ 'fi. 7 Ti ~11 TJ\1 <ffi

~ l<l; milT

UR!II/ Branch

(Sched uled Bank/P.O.) Under Intimation to me .

3llt.\l'l>.~- om~

(~til'~ .. tmft/ 'f!l ~ ~ ~ ~mrr.t ~

(31fltl! te<tR: l'l-.fi ffir.;- ;.j)-.) eli 'nl

..mr-rr it

l\ f.F

mnr -.f.\ fttfi't /

I IFS Code .......... .. ........................ .. .. ........................... .

llR!Il lf\'1 ~ 'lffi I Full Address of the Branch

Please attach a copy of cancelled/ blank Cheque)

V!l<ll

To the address given against item No.7.

~<f. q,, "fil'i/ Name of the Bank .......... ..

(b) By account payees cheque

electronic mode sent Direct for credit to my S.B. A/C

l1'1JTfilru ~~

'R I

'fl./ S.B Account no ..................... ................. ......... ........ .

~)

(Advance Stamped Receipt furnished below)

that the particulars tire tr ue to the best of my knowledge .

'r'f ~ <f; Jl'FlR ~ ~ m!'t t 1 Certified

Dutc of Juining the Eooo~ti.>lniiCUt. .

"7W<1 ~/Date of Birth .......... .. .. .

'im'j. flm '411

11>1 31~"11 Contribution for t11c cunent

"'n:l'

llil'<l
Month

Contribution
>r.!{

t.~::E
0

ll

w.

EM=EE

"'f.'l."
EPF

q,q,

FP

'!1!1'"11

Period of Break if ~y
~~~lorn
"F'

Month

EMPLOYERS
11'.'1.

Q.Q.

fll.

FP

EPF

Mnrcb
oiC<r April
~~ Moy
1'1:~ June
VI~~ July
"''rfll August
'!1;1

# ~ 1i> llmlmi Member 's Signature

Form 19 (www.epfindia.gov.ln)

Financial Year (l'c<! 2012-13 <WI. ,~)(Not applicable from 2012.13)

_,.,'ll\~_~!lm

li>~'!Rl

TOTAL

ifi."f.

q,Q.

flt

FP

EPF

annrn--'!,..l1i 1l~~lll l1l

"""""

Contnbution

~ ...EMPLOYEE

ii

C!

i~...

fllii"'R

~.

r~.

Penod of Break if any

H<it<mo

'!l<'l

EMPLOYERS

TOTAL

l!.Q.

1fi.'f.flt

Q,q,

...'l.f-1 .

qA

FP

EPF

FP

I>PF

FP

EPF
September

~Occobcr

.,_, November
~~ December
"'lift~ Janua!:l:'

"''oil February

-# f.\tl)qnr </;
Page I of2

--

lmll!ff<' /Employ's Signature

J~'

WI~ 1~1 ilflffi

111~

or~

'l

ml!"' Jl'.'!!!l~

(llfc1 ~Tlll !lll'l f.'!mr &H'I 'ffi'<llfrtff lllrm '1'!11 ~ <n ~ :q:;Frr ~ mr ~ ;;n~}
(Informal ion to be fumishcd by the Employer if the Claim Form is Attested by the Employer)
.
t fll; ~ 3im:R f.'!mllo' l!!Rr<fi vrm Q'f ..ntl >i 'tt~ t !/Certified !hal the above contributions have been included in
the regular monthly remittances.

~I 31>[& .l'f'JI'!J..!LThe Applicant has signed/thumb .impressed before me.

~ ~ lOffiTm 3!~ <~'fli /1:T'Ii ~;~ ct. w~ <~>1 f.mr-'1
Signature or Let\ I Right hf!lld thumb impression of the member

f.'I<Wlm If; irnlW< I Signaturc of Employer

,,

frlfil/D~te ........... ..
f.t'l!)lf<ll ltil 'lG''ifll ~ ~~

Designation & Seal of Employer

~/Encl.

~ 11 ~ liT-'1 ~ ~I Declaration of non-employment

.
fto.l1lj) : 1fi.'l.f.!l .
1952 <5 ttxr sg 'li \Jll-~ (2) tf; ~ () Jft~ ~-"xr (1) -.t. ~ ('1) ~ 3R'llhl f'rq-er-r ~ fffi1
'ifi~ <6 lfll''l .q l:W ;ftlf;{l
~ <Gi <lTfuq fl
~ ~ 'ilK ~ <IR"Tl ~'! urJ ~ OflTltlf{ ~ W b't 3le<<lf l[;il ~ tj 1fi1"lRrr it R;rn 'R ~lf'l <'H'J, 9'Sl ~ I

mvr-n

3!Tm

en

Noto: In the cuse of submission ofupplicution for settlement under clause (S) ofsub-p"ragraph (i) and in clause (b) of Sub parngrnph (2) of paragraph 69 of the
EPF Scheme. 1952 the claim should be submitted after two months from !he date of leaving service provided the member continues to remain un-employed
in an estt. to which the Act applies.

m3tt):a

'G<~
l\''Rll!H~ 3lor<ll i!tl/ 1 <!!'i N'll
ltil f-f~TR
~
Signature or left I Right band thumb impression of the member
3lfuq ~ <'f"lf\ ~ (<l>'<fR '\'J'RT<f(l S(~Cq) <f; lJToni! lj lrf\.');<1 >t) Vfl'i)
ADVANCE STAMPED RECEIPT (To be furnished only in case of 8(b) above)

~/On'&_

----

~~ 11~ AA 3!!?!'1/'II"!RR \Jti-Nrn ~ ........................................................................................................................ " 3!lH 'l~ f.!\f1 {111ft ct. f.'ttrm tR
~"'"''"'''""'''' '' ' '" ' ''' H"
c:6'1 ~~fu 31~ ~ tifi ~~ i1 ~~'<I~~
.~
Receive<! a sum of~ ........................................ .................. .. . ( ~ ........... .............. ................................ ....... ............ only) from Regional Providcni,Fund
(

t,,,

.. ' - ' ' ' ' ' ' ' ' ' ' ' ' " ' ' '0-00000 .. 00000oOooo"O .. OO"O"OUo .. )

Commission/Officer-in-Charge of Sub Regional Ofllcc ................................................................. by deposit in my SaVing Bank account tow<1rds the set~lemcnt of my
Provident fund Account.
1.00 ~

Affix I .00 ~ Revenue

Stamp

,.,. ..

: ~~.l- 'ffi
... ,.;I ~Fo!' !b':" ~"'"P .!f.'fCommis~.ioner's . o.ro ~~) .
~ fi};1rr lfllti'Wf ~. 2H1/2 om~ ~/3 tr. ~- f.l. ~ 9 {<ffirltl~) 1'i ~ qj)

<'lffi 1fiT

Nc. Settled in Part/Full Entered in F-21 -A/2 and withdrawal Register/ Form 3 (F.P.F.) Form 9(Reviscd)

m.~~

SSA
~

-.f> ~I Undor Rs ................................ ........................ ........ .. ........... ................................................. .. ................................ ............. .. ... ......... .
~3!Tt~/~
M.O./Chcquc

'Tf'IR "1<:' 'fl.

P.I- No.
~:t)

1ii

'1'l(lf-'! <I;

IW:i

l!fff

Ulffi ~.

Account No.

f4irn I Passed for payment for

:r

Accounts Officer
~f<l;

Dated

('l'tiiiii 3fTIT'T ii !H!Y'ii ii

Paid by cheque No. .... .................. ............. ... .................. .. ..... ... .........

f~/ (FOR USE IN CASH SECTION)

~"'tifi

~'!~

.. ............. .... .. . . Vide cash book

.. .. Date .... ..

ct. 'GmT mm- 10 lfl<' orr" -mm ................................................................. . ............................ r.m fc);1n 'lm 1
and Account No. I 0 Debit item No.
- - - - - ~ qq_ _L

ss

J<'orm 19 (www.epfindia.gov.in)

'fl.3!!./~l.3ll I

A.C.IR.C.

~m/REMARKS

Page 2 of2

.
~

'

I,,

~ ~-1 Mobile Number

I

~ ~ ~ ~/ For Office Use Only

Gl<IT ~/Clam

~ ~

I.D ............................................. .

;mur-rr ~ <$ ~ E ~ tm<rr 'Gil"l '1l1ffi wrn 1o ~

FORM lOC FOR CLAIMING WITHDRAWAL BENEFIT/SCHEME CERTIFICATE

~. 1995 EMPLOYEES' PENSION SCHEME, 1995

wrn ~ ~ ~ ~ "<Pl '9#/(Read the instructions before filing up this form)

mG m:<m11 180 ~ ~ 3W:rlfi 00 i) "iJii <IR), ~ (f)lf <ilt t '\Rmm 'ID'1 "hi "lt) i l \VITI-lORA\VAL BENEFIT IS NOT ADMISSIBLE IF

MEMBERSI-ITP IS LESS 11-IAN 180 DAYS EXCLUDING NON CON1RIBUTING PERIOD

(<!i)

l!il "fill (re 3Jffil 'l) /

(~) G'TilGR <1>1 "!Jll

Name of the Member {In Block Letters): - - - - - -- - -- - - - - - -

Name of the claimant (s): - - - - - - -- -- - - - - - - - - - - - - - - - - - - -

~ ~121/Date of Birth
''

\'

filwllil

qfcl

"!Pl /Fath er's

l!il 'WI

(dd/mm/yyyy)

'----'------'1 .__I__,____.I ._I_I'---'_____.___

Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ __

Husband's Name {If applicable). _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

4.

5.

Name & Address of the

Establishment in which; - - - - - - - - - - - - - - - -- - - - - - - - -- - -the member was last employed .
..
<P'l<l ~- n\'.11 W<T~ <i.

a)~ I <i>T ~
~~ q,~ <J>lii --H.
Wffi ti.
Code No . & Account No.
Region/Off Code
Estt. Code No.
A/c No .

. 11.,____,____,__~1 .___I_ ____.IlL_____

,_,__I.

SA)
6.

______.

~~ Fc!12i; Date of Joining the Estt. - - - - - - - - - - - - - - - - - - - - - - - - <'len~ l!il <PRUJ nm

<'1<n ~ if,) Fc!l2!

Reason for leaving service &
Date of Leaving
'],'{~ '!<II (re 3fen'f il)

Full Address {In Block Letters) - - - - - - - - - - - - - - - - -- - - - - - -- - ~/~ /~/ Sh.

'T'J/'l'Al/~ / 5/o,

/ Smt. /Km . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

W/o, 0/o._ _ _ _ _ __ _ _ _ _ _'Cfffi/ Adress _ _ _ _ _ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ftR/PIN _ _ _ _ _ _ __

~ ~ m~m 31\'.fCTJ iff\[/GJl:! l;lU mJilrP

l!il

f'I>~TR

it f.l~

<(; ~m / Employer's

Signature

Signature or Left/ Right hand thumb impression of th e member

Form lOC (www.epfindia.gov.in)

Page

1 of 4

<m l <~rrq ~<J>R\1 4~i'l l' l <1~ '~'-~"" 4< "ll)iil"' l

WIJUI~ ft<J>R <vx."\ <i> f<""'l (hR i) I

8.

r,'l ves

>rtn

NoD

Are you willin g to accept Scheme Ce rtifi cat e

in lieu of withdraw al benefit s
mG-~

1ao

~ ~3hrzyft.m<ilt~~. ~1!)1{<6\t-m ~('fl'll~'ltt ~ ~

Withdrawal benefit is not admissible if the membership is less than 180 days excluding non contributory period of service.
q~ <Til fclqxUI

9.

(qf<l I q'A) \'121"1 <rLil \'1211 'llii1f<l)

Parti culars of Family {Spouse & Children & Nominee)

(fuqf ~

WfTUT ~

cf

cf

"!Pl

Name

4R<Ti<

Family members

(~)

(b)

Nomine

f<l"'l

Dat e of Birth

Relati onship with M ember

"11<!1 ~

<i>

3lf<l1lli'fifi <Til "'Pl

Name of th e guardi an of min or

<!'> ~

(<!i)
(a)

10.

~/a ppli ca bl e only for Scheme Certificat e opti on)

iJf-"1 ffil[j
~~ <!'> <1121 "fi<il'l

"GT<ll fcl~ 58 <11! <1\1 3~

l!ll(f

<!i<"' <J'i

iiTG ~ <1\1 ~

!;).'\ 4<, -

In case of death of members aft er attaining th e age of 58 years without filling th e claim :-

(<!i)

<1~ <1\1 ~ <1\1 ffil2:i; Dat e of death of th e memb er

(~)

Gf<'tGR)

\./~

<1~ "!Pl/<1211 ~ ~

IT-1\)l'fUl <Til

\3'ffiil

-wit~ 1 Name of the Clamin ant( s)/and relationship with the member

>n~ll (fil~rm f<lfQ <1'> 3r:J<ll< ~<ifQo <Til-.e<~>

1)

~<1> ~)

Mode of remittance (put a ti ck in the box aga inst the on e o pted)

TfG ~. 7 1) ~([ tR) l]X 1)~ C'!Pl(f 4< '51<!> 'T'fl3li.R lll<l

(<!i)

By post al mon ey ord er at my cost to the address given aga inst item No.7:
~) ~<I""" s~ 11~ <!<:!<! ~m 1 ~. (<~IJW'<!<i l'fq,;;s~) 1) fflf<li<r ~<!>/ ~<'1<15;l~<~> >nUPl ~ 31TGRll &11'11 l'llil *m "'T([/ (b) By account
payees chequ e/ electron ic mode se nt Directly for credit to my S. B. A/C (Scheduled .Bank / P.O.) und ~ rintimation to .me..

(~)

~ l'fq, ~lffi ~/S. B . Account No.

llq, <Til "!Pl (~ 31m ) ii; Name of the Bank {In Bloc k Lett ers)
'ITffiT (~ 31eR) 1)) 1 Branch {In Block Lett ers)

m; IFSCode

<~mf.~.~

~rrm <Til '1-Xl rmr (<4!C 31~R) 1))/Full address ofth e Branch {In Block Letters) :

(m

t.P W<l

'*

~/" $!>

cCt 1l'l!>llftr~

<m~ <~1T4 <!i.il. "llt 95 <~'> mo r)~""

12.

1Jl1(j

q;x

~Please attach a copy of cancelled/blank Cheque)

<t! t:

Are you availing pension under EPS-95 ?

r,ij Yes

mGm. m~<~ ~

q)

If yes, indicat e

PPO No ... ............... .

fcnm

\ilTifT ~

fu> fclcRur iR

q\311

~ W'1

~.

cf 3TjfiR

~/ No D

f<l,-wf; &m ~
By whom iss ued ......................................................... ....... .

"fffll ~ /

Certifi ed that the particul ars are true to the best of my knowl edge

~/Gf<'tGR <)> r,<lel< 312f<IT <n~ tn'!-1 <J> 3flJP <Til ~W"' ~
Signature or left Hand Thumb impress ion of th e Member/Claim ant

fcl"!iq;
Dat e ........... ............

# ~<l)q\'(1 <i> r,<llll< / Employer' s Sign ature

Form lOC (www.epfindia.gov.in)

Page

2of 4

'

' I

3Jft:ITJ ~lfi<l ~G

Advance Stamped Receipt

(<t<lOl ilitlx (<JJ) <1~ ~ ) t.l 1RWJ f<h<n iJl~)
[To be furnished only in case of (b) above]
~

* f.lqcA ~ ~)il<J 1f<l~ f.JfEI 3ffg1l<'l/IJ'I- a-tltll <Pmi<'lll <1~ ~r1Ji't 3rfiT<l>Ji) <) 3fQ~ ifffi'l ~<~' <JJITl i\ \JPn li"~<T

f.Jft'l <JJm

ilm

('il<G11) ...............
(!\) 'lf~l \111{1 (!\)I
Received a sum of L ....... ...... .... ............ ......... (Rupees... .
...... ........ ... ...... .... ..... ......
.... .. ...... ..... ... ... ) only from
Regional Provident Fund Commissioner/Officer-in-charge of Sub-Regional Office .... ... ..... ........... by deposit in my
savings Bank Nc towards the settlement of my Pension Fund Account.
off"~)) ffitli ~'! ~ 'IQ.TA <!i'l ~~ rf1lti11 f.Jft'l 3JT<'1/lfiTJi't 31ft'!~ linT RT ~ I
The space should be left blank which shall be filled by Regional Provident Fund
Commissioner/Officer-in-charge)

HO

OH

~m 3ft< ifu m~ <i'i 3flJP

H..

~ 1 Revenue
Stamp

f.i'm

Signature & left hand thurnb impression of the member on the stamp
"' 'ITG'Ill <i'i

1l>1

wrrfttr<r !11>1:11 \JTRll ~ ftli <TG<ll li"~<l ~I!" flt<RuJ -m1 ~ 3ft< 'ITG'Ill ~ )~ WleJ ~~R f<h~ V 3[1~01 f.Jm wrr;l \l r
Certified that the particulars of the member given are correct and the member has signed/thumb impressed before me .
'llGW

<1ft ~ ~ ~ 3hiGT1fi ~ <t; fimvr ~ t :-

The details of wages and period of non-contributory service of the member are as under:
(ll'P.I-3~/ 7) (<1' ti1!)) "f1 3T<!ft'i 1!>1 ~ t:
3T<Ift'l -r,-g 1l <!>'1'tni'l ~ f.lfQ <l>Tiii<'lll <!Jl tJ) '1iTI TJl.! il 1)
(Form 3N7 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund Office)

"
'

'

~"''i<li 15 11 95 q;) ~ (~ ~"I + 'fii1nl! 'I'll) (mG' Ol1'J. t\)

VI/ages (Basic +0 ..!\.) ns on 15.11 .95 (if applicable)
~<11 ~ (!\) f<'IIQ:j </Jl ~
Wages as on the date of exit
Jr~ ~en <1\l 31<1ft'l :
Period of non contributory Service :
ll>l;rm;
Year/Month

'll<

~"'

No. of days
f.n:r)<lffi/m~ 3rft'l~ <1~ ~m

~"''i<li

Signature of Employer/Authorised Official

Date ......... ...... ...... .... .

3Tnjll\'1 ~ ~

lnil-rncl (For the use of commissioner's office)

~
~ 31~"1/31Gf1lTfl '1<: fi . .

rRl3TIJ<i/~
Under ~ ... ............ ... .................. ...... ................... .... P.I.No .. ... ... ..... ..... .. .... ......... .. ..... ..... ... ................ .... M.O./Cheque .
~ ........................................................ 'il<G11 ..
...........
(!\) 3JGTilTfl f,g ~ f<h<n I

OH

OO

Passed for payment for~ ... ............ ... .. .... .. (in words) ..... ............. ............. ... ...... ... .... .. .. ... ..................... ... ............. .... ...
(m'G ~ t\) ........................................................................................... f.r<nRi1 q~nT (!\) f.J<!Ol ~r ..

1Fft311J<i ~

M.O.Commission (if any) ....................................... net amount to be paid by M.O .......... ....... .. ......... towards withdrawal
benefit.

m.~.x:r.

SSA

Form lOC (www.epfindia .gov.in)

<l.<'l.31ft'l.
A.AO .

Page 3of4

('filiGTj'fTTT ~ Wl~'ll<>.\)

(For use in Cash Section)

. ~ .....

<i.-1a ~l>lc TfG <i.

Paid bi inclusion in cheque No.
item No ... ..... . ...... .. ..... .. ......... .

3l:J

. . tR

Gv\

<!iX

f<:nn

~I

......... ...... Dt .... ...... ......... . .. ... ..vide Cash Book (Bank) Account No .10 Debt

'l<l.

('l'PG)
AC (Cash)

<l 3!R'l.

S.S
t;<l. t;<l . . \iTR) ffl ~ ~ 3n{ <ft. t;<l ~ ~
For issue of S.C ., IDS is enclosed

m:~x:r.

3fj. q<j

SSA.

S.S.

<l~.3H

AAO .

<Ptf.l.3n. (<il<S~ l)

APFC (Ales.)

(~A 3l'Jwr ~ wnlw.f)

(For use in Pension Section)

. ..... ....... ...... ....... "~ t

<!it Ro1i<l> ... -

Scheme Certificate bearing the control No ....................... .. ... .... ..... issued on .... .. .... ............... ... .. ... ... ................ and
entered in the Scheme Certificate Control Register.

m.XJ.x:r.
SSA

3fj q<j

S.S.

Form lOC (www.epfindia.gov.in)

<~.<!1.3n.

A.AO .

" '!. f.l3n

(ffim)
APFC (Ales.)

Page

4 of4

tv\~~

"FORM NO. lSG

(}

~y ff

)See section 197A( 1), 197A( 1A) and rul e 29C)

Declaration under section 197A(1) and section 197A(1A) of th e Income -tax Act, 1961 to be made by an individual or a person (not being a company or firm) claiming
certa in receipts without deduction of tax.
PART I
'\~PAN of th e Assessee
\.~Name of Assessee (Decla rant)
3. Assessment Year
( for which declaration is being made)
4. Flat/Door/Block No.

5. Name of Premises

8. Road/Street/La ne

9. Area/Locality

11. Town/City/District

12. State

6. 'Status
7. Assesse d in which Ward/Circle
10. AO Code (unde r whom assessed last
time)
Area Code

14. La st Assessment Year in w hich

assessed
17. Present Ward/Circle
18. Residential Status (within th e
meaning of Section 6 of the Income Tax
Act,1961)
)LU. resent AU Code (if ~g;same .as
above)

113. PIN
15. Email

lAO Type IRa nge Code lAO No.

16. Telephone No. (with STD Code ) and M obile No.

19. Name of Business/Occupation

21. Jurisdictional Chie f Commissione r of Income-tax or Com missioner of Income -tax (if not assessed to
Income-tax earli er)

Area Code

,:

lAO Type IRange Code rONo.

22. Estimated to tal income from the sources mentioned below:

(Please tick the relevant box)

D
Dividend from sha res refe rred to in Sched ule I
Inte rest on securities referred to in Schedule II
Interest on sums referred to in Schedu le Ill

Income form units referred to in Schedule IV

The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred to In ScheduleV
23. Estimated tota l income of the previous year in which income mentioned in Column 22 is to be included
24. Details of investments In respect of which th e declaration is being made:
SCHEDULE-I
(Details of sha res which stand in the name of th e declarant and beneficia lly owned by him)
No. of
Class of shares &
Tota l val~e
shares
Distinctive numbers of the sha res
face value of each
Date(s) 0n which the shares were acquired by the
of sha res
declarant(dd/mm/yyyy)
sha re

SCHEDU LE -II
(Details of the securiti es held in the name of declarant and beneficially owned by him)
Description of
securities

Number of securiti es

Amount of securities

Date(s)of
securities
(dd/mm/yyyy)

Date(s) on whi ch th e securities were

acquired by the decla rant(dd/mm/yyyy)

SCHEDU LE-Ill
(Details of the sum s given by the declarant on Inte rest)
Name and address of the
person to whom th e sum s are

given on interest

Amount of
sums given
on Interest

Date on which the sums we re given on

interest(dd/mm/ yyyy)

Period for which sum s we re

given on Interest

Rate of
interest

SCHEDU LE-IV
(Detail s of the mutual fund units held in the name of declarant and beneficia lly owned by him)
Name and address of the
mutual fund

Number of
units

Class of units and face value of each

unit

Distinctive number of units

Income in respect of
units

SCHEDU LE-V
(Details of the withdrawa l made from Nationa l Savings Scheme )
Particulars o f the Post Office where the account under the National Savings Scheme
Is maintained and the account number

Date on w hich the accoun t

was opened(dd/mm/yyyy)

The amount of
withdrawal from the
accoun t

.. Signature o f the Declarant

Declaration/Vorifi cation

D
LJ

u
D

'"l/We..
................... do ~1ereby dedare that to the. best Of" my/our knowledge and belie f what is stated above Is c~.nrec.:t, comple te and is tru ly s.ta~ed. ~ 1/We
declare that the incorne5 referre d to in this form are not includible in th e total income of any other person u/s 60 to 64 of the Income-tax Act. 1961. *1/We fwther,
declare that the tax on my/our estimated total income, including,. income/incomes referred to in Column 22 above, computed in accordance with the provisions
...... wil l be n il. *1/We also, declare that my/our
. of the Income--tax Act, 1961 , for the previous year ending on .. ... ........ :...... re levant to the assessment year
income/Incomes referred to in Colu mn 22 for the previous yea r end ing on .................... relevant to the assessment year
........ . will no t exceed th e maximum
amount wh ich is not chargeab le to lncorneR tax.

Place:

~\.

Signature of the Declarant ....

Da t e:
PART II
lh)r use by th ~ person to whom the declaration is furnished]

1. Name of the per son responsible for paying the incOme refe rred to in Colui'nn 22 of Part I

2. PAN of the person Indicated in Colunin 1 of Part II

.........................................................
\

~?

3. Complete Addre"

'

4. TAN o f the person indicated in Column 1 of Part II

5. Email

6. Telephorie No. (with STD Cod e) and Mobile No.

8. Date on which Declaration is Furnished

9. Period in re spect of which the dividenq_h~s been

declared or the income has been paid/cred ited

7. Status
(dd/mm/yyyy)

10. Amoun t o~ income paid

cr~ited (dd/mm/vyw)

,.
12. Date o f declara tio n, distribution or payrnent,of dividend/withdrawa l under th e
National Savings Schem e(dd/rnrn/yyyy)

11. Date on wh1ch the int.ome

has been paid/

j13. Accpunt N~rnber o f N.ati onal Saving Scheme fro m wl.1ich withdrawal has

Ibeen made

.,;
Forward ed to the Chief Commissioner or Commissioner of Incom e-tax.

'
Place:

Date:
Signature of the person respons ible for
paying the income refe rred to in

ll

Column 22 of Part I

,r -,

Note s:

,,

l.
2.

The declarat ion sho uld be furnished in duplicate.

*Delete whichever is not applicable.

3.
4.
5.

"Declaration c.a n be furni shed by an individua l under sec.tion 19/A(l.) and a person (ot her than a company o r a firm ) under section 197A(1A).
"'Indicate the capacity in which the decl aration is furni shed on behalf of a HUF, AOP, e tc.
Before signing the declaration/verificatio n, the declarant should satisfy himse lf that the information furnis~red in this forrn is true, correct and complete in al l
respects. Any person making a false st atemen t in the declaration shall be lipble to prosecution under 277 ?f the lncomeRtaX Act, 1961 and on convictio'rl be
punishable --

,,

!) In a case w here tax sough t to be evaded exceeds twenty-five lakh rupees, with rigorous imprisonment which shall not be less t han 6 months but which
may extend to $even years and with fine;

,,.

ii) In any other case, with rigorous in{pri sonment w hich shall not

f.
6.

b~ less than 3 months but which m ay extend t o two years and with fine .

The person responsible for paying the income r eferred to in colu mn 22 o f Part I shall not accept the deClara tion where the amount of income of the nature referred
to in sub-section (1) or sub-section (1A) o f section 197A or the aggregate of the amoun t s o f such income credited or paid or likely io be credited or paid duri ng the
previous year in which such income is to be include d exceeds th e maximum arnount which is not chargeable to tax.";

,..

. '

[
"FORM NO. lSH
(See sec tion 197A(1C) and rul e 29C(1A)]
Declaration under secti on 197A(1C) of the Income-tax Act , 1961 to be made by an Individual wh o is of th e age of sixty yea rs or more claimingce rtain rece ipt s
without deduction of tax.
PART I
'II.. Y.Name of Assessee (Declarant)
\ i;k1'AN of the Assessee

- ~ ~-

3. Age
5. Flat/Door/Block No.

6. Name of Premises

8. Roa d/St reet/Lane

9. Area /Loca lity

11 . Town/C ity/ District

12. State

15 . Email

16. Telephone No. (with STD Code) and Mobil e No.

Assessmen t Year
(for w hich decl aration is being'\nade )

7. Assessed in w hich Ward/Circle

10. AO Code (under whom assessed last
tim e)
Area Code lAO Ty~ r ange Code

r O No.

,13.PIN
14 . Las t Assessment Yea r in which assessed
17. Prese nt Ward/Circle

19 . Prese nt AO Code (if not sa me as above)

18. Name of Business/ Occupation
20. Jurisdiction al Chief Commissioner of Income-tax or Commisslo ne' of lncome-tax(if not assessed Area code r o Tv pe r nse code
lAO No.
to Income-tax ea rlie r)

21. Estimated total income from the sources mentioned below

(Pl ease ti ck th e relevant box)
D
Dividend from shares referred to In Schedule I
D
Interes t on securities referred to in Schedule II
D
Interest on sums referred to In Schedule Ill
D
Income from units referred to in Schedul e IV
The amou nt of with drawa l referred to in cl ause (a) of sub-secti on 2 of sec ti.o n 80CCA referred to In Schedul e V
D
22. Estim at ed total income of th e previo us yea r in which income mentioned In Column 21 is to be includ ed
23.Det ails of investments in respect of which th e decl aration is being made:
SCHEDULE -I
(Detail s of shares which stand in the nam e of th e declarant and beneficially owned by him)
Class of shares &
Date(s) on w hich the shares w ere acq uired by th e
No. of
Total value Di stin ctive num be rs o f
face va lue of each
the shares
declarant(dd / mm/yyyy)
5hares
of shares
share

Description of
securities

SCHEDULE-II
(Detail s of the securi ties held in the name of decla rant and bene fici ally owned by him)
Date(s) of
Date(s) on which th e securiti es were acq uire d by the
Amount of
securities
Num ber of securities
declarant(dd/mm/yyyy)
securities
(dd/mm/yyyy)

SCHEDULE-Ill
(Detail s of th e sums given by th e declarant on Interest)
Name and address of t he
Am ount of
Da te on which the sums we re
person to whom th e sums are sums given
give n on interest(dd/mm/yyyy)
given on Interest
on interest

Period for which such sums we re

given on inte rest

Rate of
interest

SCHEDULE-IV
(Details o f th e mut ual fund units held in th e name of decla rant and beneficially owned by him)
Inco me in res pect o f
Name and address of th e
Number of Class of units and fa ce
Distinctive number of units
units
mutual fund
va lue of each unit
units

SCHEDULE-V
(Deta ils of t he withdrawal made f rom Nationa l Savi ngs Scheme)
Particulars of the Pos t Office where the account under th e Nati onal

Savi.ngs Sche me is mainta ine d and the account numbe r

Date o n which the account w as

opened(dd/mm/yyyy)

The amount of
withdrawa l f rom the
account

"?.
~ Signature of the Decla ra nt

Declaratio n/Vcrificati on

1..
. ..... do hereby dec.lare that I am residenti n India within the n1eaning of section 6oft he lnc.ometax Act, 1961. I also, he reby declare thatt o
the best of my knowledge and belief whati s stated above is correct, complete and is truly stated and thatt he incomes re fc~rred to in this form are not
includible in the total income of any other perso n u/s 60 to 64 oft he Income--tax Act, 1961. I further, declare thatt he tax on my estima ted total incom e,
including" income/incomes referred to in column 21 computed in acc.ordance v.Jith th e provisions oft he Income tax Act, 1961, for the previous yea r ending on
... will be nil .
relevant to the assessmerit ye ar.

...................... ........................

Place:
Date:

Signature of the Decla rar1 t

1. Name of the f'Jerson

responsible~

./'

\,../'"

PART II
!For use by the person to whom the declaration is furnished]
for paying the income referred to in Column 21 of Part I
2. PAN of the person indica ted in Column l of Part It

3. Comp lete Addrc:ss

4. TAN of the peroon indi cated in Column 1 of Part II

........, ____,____ ,_,, ______________,.....-..

5. Email

8. Date on which declaration is furnished

(dd/mrn/yyyy)

---

-- ---

6. Telephone No. (with STD Code) and Mobile No.

9. Period in respect of which the dividend has been

decla re d or the incom e has bee n paid/credited

7. Status
10. Amount of incorn e paid

:11. Date on which th e

ncorne has been paid/
credited(dd/rnrn/yyyy)

12. Da te of declaration. distribution or payment of

dividend/withdrawal unde r th e National Savings
Scheme(dd/mm/yyyy)

113. Account number of National Savings Scheme from which withdrawal has been made

Forwarded to the Chief Commissioner or Commissioner Of Income-tax .................................................... .

Place:
Date:

'

Signature oft he person responsible for

paying the income r~f~rreci tn in Column
l 1 of Part I

Notes:
l.

2.
3.

4.

r'

The declaration should be furn ished in duplicate.

Delete whichever is not applicable.
Before signing the verification , the declarant should satisfy himselft hatt he information furnished in the declaration is true, correct and complete in atl
respects. Any person making a false state mentin the declaration shall he liable to prosecution under 277 oft he Income -tax Act. 1.961 and on conviction be
punishable ..
tw enty ~ five

i)

In a case where tax soughtt o be evaded exceeds

which may extend to seven years and with fine;

lakh rupees, with rigorous imprisonment which shall not be less than 6 months but

ii)

In any other case , with rigorous imprisonment which shall not be less than 3 months but which may exte.nd to two yean; and with fine.

Tt1e person responsible for paying the income referred to in column 21 of Part I shall not acceptt he declaration where th e amount of'i ncorne oft he nature
re ferred to in section 197A(1C} or th e aggrega te oft he amounts of such income credited or paid or likely to be credited or paid during the previous year in
which such income is to be included exceeds the maximum amount which i5 not chargeable to tax and deduction(s) under Chap t er VI-A, if any, for which the
declarant is eligible.";