Employees' Provident Fund Organisation

Ministry of labour and Employment (Govt. of India)

Regional Office, Delhi (South)
EPFO Complex, Plot No. 23, Sector-23 Dwarka, New Delhi-110075
FORM N0.15G
(See section 197A(l), 197A(1A) and rule 29C]
DedaratlOn under section 197A(l)and section 197A(IA)or the Income-tax P.ct,1961 to be made by an lndlvklual or a person (not being a oompat'l'f or firm) dlmlng
ceru11n receipts without deduction of tax.
PART!
1. Name of Assessee (Dedarant)
2. PAN or the:
3. Assessment Year
(for which declaration is being made)

4. Rat/Door/Block No. 5. Name of Prem1~ 6. •status

7. Assessed In which Ward/Orde
10. AfJ Code(under whom assessed last
8. Road/Street/Lane 9. Area/Locality
time \
NU c.ode INJ -.ypel R.an!le Code INJ No.
11. Town/Oty/Dlstnct 12. State
113. PIN 14, Last Assessment Year In which
assessed
16. Telephone No. (with STD Code) and Mobile No. 17, Present Ward/Orde
15.Emall
I B. Residential Status (within the
19. Name of Bus1ness/Oca.lpation meaning of Section 6 of the Income nix
Act, 1961)
20. Present AV1...0CJe (1 not same as
aoove)
21. Junsdlctlonal Chief Commlss10ner of Income·tax or CommI55Ioner of Income-ta~ (if not a55essed to Area Code"lAO T'ypelR.3n!iJ' c.ode I"° No.
Income-tax eartier)
22. Estimated total income form the sources mentioned oelow :
(Please tick.the relevant box)
Dividend from shares referred to In Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to In Schedule m
Income form units referred to ln Schedule IV
The amount of withdrawal referred tom sect10n SOCCA(2)/a) from National Savinos Scheme referred to In ScheduleV
23. Estimated total tncome of the previous year In which income mentioned In Column 22 is to be mduded

Details of Investments In respect of whidi the dec1ara tJon 1s being made:

SCHEDULE·[

.
(Details of shares, wnicn stand 11\ tnc name of the dedarant and beneficially owned by him)
No.of Cass of shares& DIst1ncuve numoers of the shares Date(s) on which the shares were acquired by the
, .., race value of earo
Total value
of shares
declarant(dd/mm/yyyy)
share

SCHEDULE-II
(Details of the securities held in the fldme of declarant and benefldally owned by him)

Date(s) of securities Date(s) on which the securities were

Description of Number of securities Amoun t of securities acquired by the dedarant (dd/mm/yyyy)
(dd/mm/yyyy)
securities

SCHEOULE•lll
lOetarls of tne sums c Iven D the dedarant on mterestl
Name and ad~r~ of the Amount of Period for which sums were Rate of
Date on wnich the sums were given on
person to whom the sums are sums given
interest (dd/mm/yyyy) given on interest mterest
given on mterest on Interest

SCHEDULE-IV
(Details or the mutual fund units held in the mime of dedarant and beneficially owned by hfm)
Income ln respect of
Number of Oass of units and filce value or each Distmctive numbers of units units
Name and address of the
mutual fund units unit

SCHEDULE-V
(Details of the •1,1thor,1wal made from National Savings Scheme)
The amount of
Date on which the account
Particulars of the Post Oftice wnere cr,e account under tne Nat ional Savings Scneme withdrawal from the
was opened(dd/mm/yyyy) ac.count
IS maintainea 3nd me account numoer

""Signature of the Dedarant

 Declaration Nerification

*lfWe .........................................................do hereby declare that to the best of •my/our knowledge and behef what is stated above is correct, complet;e and is truly
stated. *l{We declare that the incomes referred to in this fonn are not includ1ble ln the total mcome of any other person u/s 60 to &1 of the Income-tax Pa. 1961
•lJWe further, declare that the tax •on my/our estunated total mcome, including• Income/Incomes referred to In Column 22above, computed 1n accordance with the
provisions of the Income-tax Ac:t,1961, for the previous year endmg on ................... re~nt to the assessment year ................ will be nil. •IJWe also, declare that
*my/our•inccmefincomes referred to m COiumn 22 fur tne previous year endmg on .................. relevant to the assessment "fear ................. will not exceed the
maximum amount which 1s not chargeable to income-tax.
······••·····························"'''''''''''''''''
Plaa!: Signature of the Declarant
Date:
PARTII
[For use by the person to whom the declaration 1s furnished]
2. PAN of the person indlcated in Column 1 of Part 11
1. Name of the ~ n responsible for paying the inr.ome referred to in COiumn 22 of Pnrt I

3. Complete Addn,ss 4. TAN of the person indicated in Column 1 of Part U

s. Email 6. Telephone No. (with STD Code)ano Moolle No.

7. Status I
11. Date on which the mcome
IO. Amount of income paid
8. Date on which Oedaration 1s Furnished 9. Period m respect of whith the d1v1dend has been has been paid/
declared or the mcome has been paid/credited credited (dd/mm/YYYY)
(dd/mrnJyyyy)

12. Date of declaration, distribution or payment of dividend/withdrawal under the ,13. Account Numbcc of National Saving Scheme from which withdrawal has
National 5avings Scheme(dd/mm/yyyy) been made

Forwarded to the O'lief Commissioner or Commissioner of Income-tax.................. .

Place:-
Date: Sig.nature of the person responsible for
paying the income referrea to In
Column 22 oi Part l

Note-s:

1. The aedaration should be furnished in duphcate.

2. •Delete whichever is not applicable.
]. "Declaration can be furnished by an 1nd1vidual under section 197A(l) and a person (other than ,1 company or a firm)under section 197A{1A).
4. ••Indicate the capacity m which the declaration is furnished on behalf or a HUF. AOP, etc.
s. Before signing the dedaratian/verification, the dedarant should saUsfy himself that the information furnished in this Form 1s true, correct and complete in all
respects. Any person making a false statement ,n the declaration shall be hable to prosecution under 277 of the Income-tax Act, 1961 and on conviction be
punishable-
i) In a case where tax sought to be evaded exceeds twenty-five lakh rupees, with rigorous us impnsonment which shall not be less than 6 months but
which may extent to seven years and with fine;

ii) In any other case, with rigorous 1mpnsonment which shall not be Jess than 3 months but which may extend to two years and with fine.
_ The person responsible for paying the income referred to In column 22 of Part I shall not accept tne declaration where the amount of income of the nature
6 referred tom sut,-secbon (1) or sub-sectJon(lA) of secuon 197A or the aggregate of the amounts or sucn mcome creditea or paid or hkeiy to be credited or
paid during the previous year in whrch sudl income Is to oe mduded exceeds the maximum amount which ,snot chargeable to tax:';

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