Beruflich Dokumente
Kultur Dokumente
15G
[See section 197A(1C), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A (1A) of the Incometax Act, 1961 to be made by an individual or Person (not being a
company or firm) claiming certain receipts without deduction of tax.
PART - I
Area Range
AO Type AO No.
21] Jurisdictional Chief Comm. of Income Tax or Comm. Code Code
of 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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No. of Class of shares & face Total value Distinctive numbers Date on which the shares were acquired
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)
securities
securities securities securities acquired by declarant (dd/mm/yyyy)
(dd/mm/yyyy)
SCHEDULEIII
SCHEDULE IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Distinctive
Name and address of the Number of Class of units & face Income in
number
SCHEDULEV
Particulars of the Post Office where the account under the Date on which the account The amount of withdrawal
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x
Declaration / Verification
PART - II
[For use by the person to whom the declaration is furnished]
1] Name of the person responsible for paying the income 2] PAN of the person indicated in Column 1 of
referred to in Column 22 of Part I : Part II
Column 1 of Part II :
7]
5] Email : 6] Telephone / Mobile No :
Status :
8] Date on which
9] Period in respect of which
Declaration is Furnished 10] Amount of 11] Date on which the income
the dividend has been
(dd/mm/yyyy) : income paid : has been paid / credited
declared or the income has
(dd/mm/yyyy) :
been paid / credited :
12] Date of declaration, distribution or 13] Account Number of National Saving Scheme from which
payment of dividend/withdrawal under the withdrawal has been made :
National Savings Scheme(dd/mm/yyyy) :
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Forwarded to the Chief Commissioner or Commissioner of Incometax ____________
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