"FORM NO.

15H
[See 197A(1C) and rule 29C(1A)]
under 197A(1C) of the Income-tax Act, 1961 to be made by an individual who is of the age of sixty years or more claiming certain receipts
without of tax.
PART-I
1. Name of Assessee (Declarant) 2. PAN of the Assessee
3. Age 4. Assessment Year
(for which is being made)
5. Flat/Door/Block No. 6. Name of Premises 7. Assessed in which Ward/Circle
8. Road/Street/Lane 9. Area/Locality 10. AO Code(under whom assessed last

Area Code AO Type Range Code AO No.

11. Town/City/District 12. State
13. PIN
14. Last Assessment Year in which assessed
15. Email 16. Telephone No. (with STD Code) and Mobile No. 17. Present Ward/Circle

18. Name of 19. Present AO Code (if not same as above)

20. Chief Commissioner of Income-tax or Commissioner of Income-tax(if not assessed Area Code AO Type Range Code AO No.
to Income-tax earlier)
21. total income from the sources below
(Please the relevant box)
Dividend from shares referred to in Schedule I
Interest on referred to in Schedule II
Interest on sums referred to in Schedule III
Income from units referred to in Schedule IV
The amount of withdrawal referred to in clause (a) of sub- 2 of 80CCA referred to in Schedule V
22. total income of the previous year in which income in Column 21 is to be included

23.Details of investments in respect of which the is being made:

SCHEDULE-I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
Class of shares &
No. of Total value numbers of Date(s) on which the shares were acquired by the
face value of each
shares of shares the shares declarant(dd/mm/yyyy)
share

SCHEDULE-II
(Details of the held in the name of declarant and beneficially owned by him)
Date(s) of
of Amount of Date(s) on which the were acquired by the
Number of
declarant(dd/mm/yyyy)
(dd/mm/yyyy)

SCHEDULE-III
(Details of the sums given by the declarant on interest)
Name and address of the Amount of
Date on which the sums were Period for which such sums were Rate of
person to whom the sums are sums given
given on interest(dd/mm/yyyy) given on interest interest
given on interest on interest

SCHEDULE-IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the Number of Class of units and face Income in respect of
number of units
mutual fund units value of each unit units

SCHEDULE-V
(Details of the withdrawal made from Savings Scheme)
The amount of
of the Post Office where the account under the Date on which the account was
withdrawal from the
Savings Scheme is maintained and the account number opened(dd/mm/yyyy)
account

…………………………………………………………….
Signature of the Declarant
Declaration/Verification
 I……………………………….do hereby declare that I am residenti n India within the meaning of section 6 oft he Income-tax Act, 1961. I also, hereby 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 referred to in this form are not
includible in the total income of any other person u/s 60 to 64 oft he Income-tax Act, 1961. I further, declare thatt he tax on my estimated total income,
including *income/incomes referred to in column 21 computed in accordance with the provisions oft he Income-tax Act, 1961, for the previous year ending on
.................... relevant to the assessment year ..................will be nil.
Place: ……………………………………………….. …………………………………………………………….
Date: ……………………………………………….. Signature of the Declarant

PART II
[For use by the person to whom the declaration is furnished]
1. Name of the person responsible for paying the income referred to in Column 21 of Part I 2. PAN of the person indicated in Column 1 of Part II

3. Complete Address
4. TAN of the person indicated in Column 1 of Part II

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

7. Status
8. Date on which declaration is furnished 9. Period in respect of which the dividend has been 10. Amount of income paid 11. Date on which the
(dd/mm/yyyy) declared or the income has been paid/credited income has been paid /
credited(dd/mm/yyyy)
12. Date of declaration, distribution or payment of 13. Account number of National Savings Scheme from which withdrawal has been made
dividend/withdrawal under the National Savings
Scheme(dd/mm/yyyy)

Forwarded to the Chief Commissioner or Commissioner of Income-tax…………………………………………………………

Place: ……………………………………………….. …………………………………………………….

Date: ……………………………………………….
Signature oft he person responsible for
paying the income referred to in Column
21 of Part I

Notes:
1. The declaration should be furnished in duplicate.
2. *Delete whichever is not applicable.
3. Before signing the verification , the declarant should satisfy himselft hatt he information furnished in the declaration is true, correct and comple te in all
respects. Any person making a false statementin the declaration shall be liable to prosecution under 277 oft he Income-tax Act, 1961 and on conviction be
punishable-
i) In a case where tax soughtt o be evaded exceeds twenty-five lakh rupees, with rigorous imprisonment which shall not be less than 6 months but
which may extend to seven years and with fine;
ii) In any other case, with rigorous imprisonment which shall not be less than 3 months but which may extend to two years and with fine.
4. The person responsible for paying the income referred to in column 21 of Part I shall not acceptt he declaration where the amount ofi ncome oft he nature
referred to in section 197A(1C) or the aggregate 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 is not chargeable to tax and deduction(s) under Chapter VI-A, if any, for which the
declarant is eligible.";