INCOME-TAXRULES,1962

lFORMNO.I5H

[ section 197A(1C)andrule29CJ

Declaration under section 197A(1C) tobemadebyanindividual who isoftheageofsixty years ormore claiming certain incomeswithoutdeductionoftax.

PARTI

1.NameofAssessee(Declarant) / 2.PANofthe Assesseel / 3.DateofBirth2
(DD/MM/YYYY)
4.Previousyear(P.Y.)3(forwhich declarationisbeingmade) / 5. Flat/Door/BlockNo. / 6.NameofPremises
7.Road/Street/Lane / 8. Area/Localit / 9. Town/City/District / 10.State
11.PIN / 12.Email / 13.TelephoneNo.(with STDCode) andMobileNo.
14(a)Whetherassessedtotax4:YesNo
(h)Ifyes,latestassessmentyearfor whichassessed
15.Estimatedincomeforwhichthisdeclaration ismade / 16.Estimatedtotalincomeofthe P.Y.inwhichincome mentionedincolumn15tobeincluded5
17.DetailsofFormNo.15Hotherthanthisformfiled for the previousyear,ifany6
Total No.ofFormNo.15Hfiled / Aggregateamountofincomeforwhich
FormNo.15Hfiled
18.Detailsofincomefor whichthe declarationisfiled
Sl. No. / Identificationnumberofrelevant investment/account,etc.7 / Natureofincome / Sectionunderwhich taxisdeductible / Amountofincome

Declaration/VerificationS

......

Signature of the Declarant

I...... doherebydeclarethatIamresidentinIndiawithinthemeaning ofsection6oftheIncome-taxAct,1961.Ialsoherebydeclarethattothebestofmyknowledge andbeliefwhat isstatedaboveiscorrect,completeandistrulystatedandthat theincomes referredtointhisform are not includibleinthe total income ofanyother personunder sections 60to64oftheIncome-taxAct,1961.Ifurtherdeclarethatthetaxonmyestimated totalincomeincluding*income/incomesreferredtoincolumn15*andaggregateamountof

*income/incomesreferredtoincolumn17computedinaccordancewiththeprovisionsof theIncome-taxAct,1961,forthepreviousyearending on...... relevanttothe assessmentyear...... willbenSc.

Place: Date : Signature of the Declarant

1. SubstitutedbytheIT(FourteenthArndt.)Rules,2015,w.e.f.1-10-2015.EarlierForrnNo.15H wasarnendedbytheIT(FifthArndt.)Rules,1982,w.e.f.21-6-1982,IT(FifthArndt.)Rules,1989, w.r.e.f. 1-4-1988, IT(FourteenthArndt.) Rules,1990, w.e.f. 20-11-1990,IT(TwelfthArndt.)Rules,1992,w.e.f.1-6-1992,IT(SeventhArndt.)Rules,1995,w.e.f.1-7-1995,IT(Thirty-second Arndt.) Rules,1999, w.e.f. 19-11-1999,IT (TwelfthArndt.) Rules,2002, w.e.f. 21-6-2002,IT (EighthArndt.)Rules,2003,w.e.f.9-6-2003, IT(FourteenthArndt.)Rules,2003,w.e.f.1-8-2003 andIT(SecondArndt.) Rules,2013,w.e.f.19-2-2013.

PARTII

[To befilled bythe personresponsiblefor payingthe income referred toincolumn 15ofPartI]

1.Nameofthe personresponsibleforpaying / 2.UniqueIdentificationNo.9
3.PANofthe personresponsiblefor paying / 4.CompleteAddress / 5.TANofthe personresponsiblefor paying
6.Email / 7.TelephoneNo.(with STDCode) and
MobileNo. / 8.Amountofincomepaidl0
9.DateonwhichDeclarationisreceived
(DD/MM/YYYY) / 10.Dateonwhichthe incomehas beenpaid/credited
(DD/MM/YYYY)

Place:

Date:Signature of the person responsible for paying the income referred to in column 15 of Part I

*Deletewhicheverisnotapplicable.

lAsperprovisionsofsection206AA(2),thedeclarationundersection197A(1C)shallbeinvalid ifthedeclarantfailstofurnishhisvalidPermanentAccountNumber(PAN).

2Declarationcanbefurnishedbyaresidentindividualwhoisoftheageof60yearsormore atanytimeduringthepreviousyear.

3Thefinancialyeartowhich theincomepertains.

4Pleasemention"Yes"ifassessedtotaxundertheprovisionsofIncome-taxAct,1961 forany oftheassessmentyearoutofsixassessmentyearsprecedingtheyearinwhichthedeclaration isfiled.

5Pleasementiontheamountofestimatedtotal incomeofthepreviousyear forwhich the declarationisfiledincludingtheamountofincomeforwhich thisdeclarationismade.

6Incaseanydeclaration(s)inForm No.15Hisfiledbeforefilingthisdeclarationduring the previousyear,mentionthetotalnumberof suchFormNo.15H filedalongwiththeaggregate amountofincomeforwhich saiddeclaration(s)havebeen filed.

7Mention the distinctivenumberof shares, accountnumberof term deposit, recurring deposit, NationalSavingsSchemes,lifeinsurancepolicynumber,employeecode,etc.

SBeforesigning the declaration/verification,the declarantshould satisfy himself that the informationfurnishedinthisform istrue,correctandcompleteinallrespects.Anyperson making afalsestatementinthedeclarationshallbeliabletoprosecutionundersection 277 oftheIncome-taxAct,1961andonconvictionbepunishable-

(S) inacasewheretaxsoughttobeevadedexceedstwenty-fivelakhrupees,withrigorous imprisonmentwhichshallnotbelessthan six monthsbutwhichmayextendtoseven years andwithfine;

(SS) inanyothercase,withrigorousimprisonmentwhichshallnotbelessthanthreemonths butwhich mayextendtotwoyears andwithfine.

9Thepersonresponsibleforpayingtheincomereferredtoincolumn15ofPart Ishallallot aunique identificationnumbertoalltheForm No.15Hreceivedbyhimduringaquarterof thefinancialyearandreportthisreferencenumberalongwiththeparticularsprescribedin rule31A(4)(vSS)oftheIncome-taxRules,1962intheTDSstatementfurnishedforthesame quarter.IncasethepersonhasalsoreceivedForm No.15Gduringthesamequarter,please allotseparateseriesofserialnumberforForm No.15HandForm No.15G.

l0Thepersonresponsibleforpayingtheincomereferredtoincolumn15ofPart Ishallnot acceptthe declarationwherethe amountofincomeofthe naturereferredtoinsection

197A(1C)ortheaggregateoftheamountsofsuch income creditedorpaid orlikelytobecreditedorpaidduringthepreviousyearin whichsuchincomeistobeincludedexceedsthe maximumamountwhich isnot chargeabletotax after allowing for deduction(s)under ChapterVI-A,ifany,orsetoffofloss,ifany,underthehead "incomefrom houseproperty" forwhichthedeclarantiseligible.Fordecidingtheeligibility,heisrequiredtoverifyincome ortheaggregateamountofincomes,asthecasemaybe,reportedbythedeclarantincolumns

15and17.