"rORM NO, 15G

[See section 197A(1), 197A(1A) and rute 29cl

Declaration undersection 1974{1)and sectio. 197A(1A)ofthe lncome-tax Act, 1961to
be made by an individuator a pe6on (not being a company oriirm).taiming
cenain receipts without deduction oft.x.

1. Name of Assessee {Dedaranr)

2. PAN of theassessee l-:lw PPA 4ITI -
3 Assessment Yei,
PusHFA {for wh'ct oectararror li b.,,e^"d.)142D / 2 |
4. Flat/Door/Blo.k No. 5. Name of Premises
eoTTu -Eeu T,l F)).r-.r.- Ha45 Z Assessed in whach Ward/Circte
8. Road/Street/Lrne 10. ao Code(under whom -lleiiEEiili
uftnl i<uL3,\) P.O- FDor{eoR, a,€a code
time)
lAorvp.lRanpe codc lao N0
11. Town/City/Disrrict 12. state k=itSAL-.A, -

]r-oz-t1\teeG.- 13. PtN

15. Email
&3sA-4.
16. Telepqone No. {w rh 5l D Code) ano MoDi e No
14. Last Assessment Year in which

7. Present Ward/Circle
errr|l2aT
18. Residential Status (within the
19 Name of Susiness/Occupation
meaninB ofSedior 6 of the tncome Tax

hORl-rl\gn'/ Act,1961)
20. PresentAO Code (ilnotL6?--
21,JUrisdictionalchiefcommi.'lone'ortncome@
lncome-tax earlier)
a."" coae ho ryp. fau.g;i;;-Fai;
fiom ihe rources nenrioned betow:

DNrdend from shares referred to in Schedute I trl

tnteresron securities refetred to in Schedule l E
tnteresr on sums referred to in Schedute Ir E
Income form units referred to in Schedute tV E
norawarrererr.d ro rn sect on aL)cca la, f.or NaflonalsavhEs s.t'e.e -G.eol*,
ir wh ch n.ome mentioned n c olumn 22 isto be inctuded
sirreo,,.v E
. oAt 6Al
24. Details of investments in resp€ct ofwhich the dectaration is being made:
5CHEDUIE.I
which stand in the name ofthe declarant and

Oate(s)on which the shares w€re acquired by the

SCHEDULE.I

oate{s)on which the securiries were

SCHEDULE III

Name and address of the

person to whom the sums are Oate on which the sums Period ror which sums werc
given on inrerest given on interest

SCHEDULE IV
{Detaik ofthe murualfund units hetd in the name of and benefic,ally owned by him)

SCHEOULE.V
of the withdrawalmade from Nationa

pa.trcutarso.theposiof trc"***r**-,r,"*-*l*l*Z Date on which fhe account

15 ma,nlrr,eo ano tne.ccoLnt nJmoer / was opened(ddlmm/yyyy)
n

Printed from www_incometaxindia.gov.;n

Page 1 of 2
/
**Sisnature of the Declarant

Declaration/ve.if ication

"Vw"....-REflPi-...do hereby declare that to the best of'my/our knowledse and belief what ,s stated above is corre.t, complete and is truly stated. *l/We
declare that the incomes referred to in thisform are not inciudible ir thetotalincone of any other person u/s 50to 54 ofthe lncome tar Act,1961 *l/we further,
oe.rare Ihar rhe rav 'on my/our esnm.ted roral rrcome. rrn.ome/rn.ore\ .etered to rn Col-m. 2r above, compJlFd rn d.cordrncF wiln the orov \,ons
'ncl-drnE
o' the lncome-ra, Acr. 1s6r, ro, rhe prev,ou. yea. en","e 1t.q3..?f.e#r ,o ,'," ,,.",,-"n' y"", 2-+f.*.J., tr u" "i, . riw".rro. o"ciare rhi- 'mv/oJ,
11ncome/ir comes ,efe, ed ro
"^
cotumr 7, 'o. rhe p,evrous year enoins onzclr{/2u,"'e*nr r" rt'" ,s r"ufl"nr't"",2+.2a./2.,1j1, not exceed lre ma,,mun
'n
amount whlch is not charEeableto income'tax.

" ---;;;;;k*A; ;":i";;;-" -

to whom the declaratlon is
1. Name ofthe person responsible for paying ihe income refened to in Column 22 of Part I 2. PAN ofthe peBon indicated in Column 1of Part ll

4.TAN ofthe peEon indicated in Column 1of Pa.t ll

6. Te ephone No. (with ST0 Code)and Mobile No.

8. Oate on which Declaration is Furnished 9 Period in respe.tofwhichthe dividend has been 10. Amount of income paid 11. Dat. oh which the income

declaredorthe in.ome has been paid/credlred

12- Date ofdeclaration, distribution or payment ol divrdend/w,thd ra wa I u nder the 113.

Account Number of NationalSaving Scheme from which wirhdraw.lhrs
NationalSavin8s Scheme(dd/mm/ryyy) lbeen made

Forwardedtothe Chief

0ate:
SiEnature ofthe person responsible for
payingthe income referred to in
Column 22 of Part I

1. Th€ declaration should be furnished in duplicate.

2.
*Delete whichever is not applicable.
sDeclaration
3. can be furnished bv an ind ividual under section 197A(1i and a person {otherthan a company ora firm)under sectior 1974{1A).
**lndicate the capa.ityin which the declaration is furnished on behalf of a HUF, AOP, etc.
5. Before signing the de.larction/verificatlon , the de.larant should satisfy himselfthat the information furnished in this form is true, correct and complete in all
respects Any person ma king a fa lse statement in the declaratior shall be lb ble to prosecution under 277 of the lncome tax A.t, 1961 a nd on conviction be
punishable-
i) ln a case where tax sought to be evaded exceeds twenty-five lakh rupees, with rigorous im prisonment which shallnoi be less than 6 months but which
may exrend ro seven vea,s and wilr frre;

ii) ln any other case, with rlgorous imprisonment whl.h shall not be less than 3 months but which may extend to two years and with fine.
The person responsable for paying the incom€ referred to in column 22 of Part rshall not acceptthe declararon where the amountot income ofthe nature refered
to in sub section (1)or sub section (14)ofsection 1974 orthe affiretateofthe amounts ofsuch income credlted or paid or likelyto be credited or paid duringthe
previous year in which such income isto be included exceedsthe maximum amountwhach as not char8eable to tax.",

Printed from www.incometaxindia.gov.in Page 2 of 2