Bar Code : PAN :

B P L F 1 1 0 0 0 0 1

"FORM NO. 15G

[See section 197A(1), 197A(1A) and rule 29C]

Declaration under section 197A (1) and section 197A(1A) to be made by an individual or a person (not being
a company or firm) claiming certain incomes without deduction of tax.
PART I
1. Name of Assessee (Declarant) 2. PAN of the Assessee1

3. Status2 4. Previous year(P.Y.)3 5. Residential Status4

(for which declaration is being made)
6. Flat/Door/Block No. 7. Name of Premises 8. Road/Street/Lane 9. Area/Locality

10. Town/City/District 11. State 12. PIN 13. Email

14. Telephone No. (with STD 15 (a) Whether assessed to tax under the Yes No
Code) and Mobile No. Income-tax Act, 19615:
(b) If yes, latest assessment year for which assessed
16. Estimated income for which this declaration is made 17. Estimated total income of the P.Y. in which
income mentioned in column 16 to be included6

18. Details of Form No. 15G other than this form filed during the previous year, if any7
Total No. of Form No. 15G filed Aggregate amount of income for which Form No.15G filed

19. Details of income for which the declaration is filed

Sl. Identification number of 8
relevant Nature of income Section under which tax Amount of income
No. investment/account, etc. is deductible

RMTL
HDFC BANK LTD
© CUST ID:
© FD/RD NO :
© FD/RD NO :

9333 /05.11.2015
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :

……………………………………….
Signature of the Declarant9

Mandatory : To be filled by the Branch

Checklist for Form 15 G (For individual less than 60 years)

I have checked and confirm the below Tick (or ×)

Customer is less than 60 years (if >= 60 yrs then fill Form 15H)
PAN No. is updated in Bank Records against the Cust id of customer
Branch
Copy of PAN Card attached ( if not updated in the system)
Seal with
Customer has signed in six places (indicated by) Sign &
Fields marked © are mandatory to be filled Date
Name of the Emp_____________________ Emp. Code _________________
Emp. Sign___________________________ Date _______________________
 Declaration/Verification10
*I/We………………………………do hereby declare that to the best of *my/our knowledge and belief what is
stated above is correct, complete and is truly stated. *I/We declare that the incomes referred to in this form are not
includible in the total income of any other person under sections 60 to 64 of the Income-tax Act, 1961. *I/We further
declare that the tax *on my/our estimated total income including *income/incomes referred to in column 16 *and
aggregate amount of *income/incomes referred to in column 18 computed in accordance with the provisions of the
Income-tax Act, 1961, for the previous year ending on .................... relevant to the assessment year ..................will
be nil. *I/We also declare that *my/our *income/incomes referred to in column 16 *and the aggregate amount of
*income/incomes referred to in column 18 for the previous year ending on .................... relevant to the assessment
year .................. will not exceed the maximum amount which is not chargeable to income-tax.

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

Signature of the Declarant9
Date: ………………………………………………..

PART II
[To be filled by the person responsible for paying the income referred to in column 16 of Part I]
1. Name of the person responsible for paying 2. Unique Identification No.11
jkbnjbjhbb
3. PAN of the person 4. Complete Address 5. TAN of the person responsible for paying
responsible for paying
As per account
6. Email 7. Telephone No. (with STD Code) and Mobile No. 8. Amount of income paid12

9. Date on which Declaration is received 10. Date on which the income has been paid/credited
(DD/MM/YYYY) (DD/MM/YYYY)

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

Signature of the person responsible for paying
Date: ……………………………………………….. the income referred to in column 16 of Part I
Notes:
*Delete whichever is not applicable
1
As per provisions of section 206AA(2), the declaration under section 197A(1) or 197A(1A) shall be invalid if the declarant fails to furnish his valid Permanent Account
Number (PAN).
2
Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a firm) under section 197A(1A).
3
The financial year to which the income pertains.
4
Please mention the residential status as per the provisions of section 6 of the Income-tax Act, 1961.
5
Please mention “Yes” if assessed to tax under the provisions of Income-tax Act, 1961 for any of the assessment year out of six assessment years preceding the year in
which the declaration is filed.
6
Please mention the amount of estimated total income of the previous year for which the declaration is filed including the amount of income for which this declaration is
made.
7
In case any declaration(s) in Form No. 15G is filed before filing this declaration during the previous year, mention the total number of such Form No. 15G filed along with
the aggregate amount of income for which said declaration(s) have been filed.
8
Mention the distinctive number of shares, account number of term deposit, recurring deposit, National Savings Schemes, life insurance policy number, employee code,
etc.
9
Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
10
Before signing the declaration/verification, the declarant should satisfy himself that the information furnished in this form is true, correct and complete in all respects. Any
person making a false statement in the declaration shall be liable to prosecution under section 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 imprisonment which shall not be less than six 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 three months but which may extend to two years and with fine.
11
The person responsible for paying the income referred to in column 16 of Part I shall allot a unique identification number to all the Form No. 15G received by him during
a quarter of the financial year and report this reference number along with the particulars prescribed in rule 31A(4)(vii) of the Income-tax Rules, 1962 in the TDS statement
furnished for the same quarter. In case the person has also received Form No.15H during the same quarter, please allot separate series of serial number for Form No.15G
and Form No.15H.
12
The person responsible for paying the income referred to in column 16 of Part I shall not accept the declaration where the amount of income of the nature referred to in
sub-section (1) or sub-section (1A) of section 197A or the aggregate of the 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. For deciding the eligibility, he is required to verify income or the
aggregate amount of incomes, as the case may be, reported by the declarant in columns 16 and 18.
Bar Code : PAN :
B P L F 1 1 0 0 0 0 1

"FORM NO. 15G

[See section 197A(1), 197A(1A) and rule 29C]

Declaration under section 197A (1) and section 197A(1A) to be made by an individual or a person (not being
a company or firm) claiming certain incomes without deduction of tax.
PART I
1. Name of Assessee (Declarant) 2. PAN of the Assessee1
jbjhbhbhbhbh
3. Status2 4. Previous year(P.Y.)3 5. Residential Status4
(for which declaration is being made)
6. Flat/Door/Block No. 7. Name of Premises 8. Road/Street/Lane 9. Area/Locality

10. Town/City/District 11. State 12. PIN 13. Email

bhbhbhbhb hvgvgvg
14. Telephone No. (with STD 15 (a) Whether assessed to tax under the Yes No
Code) and Mobile No. Income-tax Act, 19615:
(b) If yes, latest assessment year for which assessed
16. Estimated income for which this declaration is made 17. Estimated total income of the P.Y. in which
income mentioned in column 16 to be included6
kjhbjhbjhvbhvhvhv jhbhhvv
18. Details of Form No. 15G other than this form filed during the previous year, if any7
Total No. of Form No. 15G filed Aggregate amount of income for which Form No.15G filed

19. Details of income for which the declaration is filed

Sl. Identification number of 8
relevant Nature of income Section under which tax Amount of income
No. investment/account, etc. is deductible

RMTL
HDFC BANK LTD
© CUST ID:
© FD/RD NO :
© FD/RD NO :

9333 /05.11.2015
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :

……………………………………….
Signature of the Declarant9

Branch
Seal with
Sign &
Date
 Declaration/Verification10
*I/We………………………………do hereby declare that to the best of *my/our knowledge and belief what is
stated above is correct, complete and is truly stated. *I/We declare that the incomes referred to in this form are not
includible in the total income of any other person under sections 60 to 64 of the Income-tax Act, 1961. *I/We further
declare that the tax *on my/our estimated total income including *income/incomes referred to in column 16 *and
aggregate amount of *income/incomes referred to in column 18 computed in accordance with the provisions of the
Income-tax Act, 1961, for the previous year ending on .................... relevant to the assessment year ..................will
be nil. *I/We also declare that *my/our *income/incomes referred to in column 16 *and the aggregate amount of
*income/incomes referred to in column 18 for the previous year ending on .................... relevant to the assessment
year .................. will not exceed the maximum amount which is not chargeable to income-tax.

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

Signature of the Declarant9
Date: ………………………………………………..

PART II
[To be filled by the person responsible for paying the income referred to in column 16 of Part I]
1. Name of the person responsible for paying 2. Unique Identification No.11

3. PAN of the person 4. Complete Address 5. TAN of the person responsible for paying
responsible for paying

6. Email 7. Telephone No. (with STD Code) and Mobile No. 8. Amount of income paid12

9. Date on which Declaration is received 10. Date on which the income has been paid/credited
(DD/MM/YYYY) (DD/MM/YYYY)

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

Signature of the person responsible for paying
Date: ……………………………………………….. the income referred to in column 16 of Part I
Notes:
*Delete whichever is not applicable
1
As per provisions of section 206AA(2), the declaration under section 197A(1) or 197A(1A) shall be invalid if the declarant fails to furnish his valid Permanent Account
Number (PAN).
2
Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a firm) under section 197A(1A).
3
The financial year to which the income pertains.
4
Please mention the residential status as per the provisions of section 6 of the Income-tax Act, 1961.
5
Please mention “Yes” if assessed to tax under the provisions of Income-tax Act, 1961 for any of the assessment year out of six assessment years preceding the year in
which the declaration is filed.
6
Please mention the amount of estimated total income of the previous year for which the declaration is filed including the amount of income for which this declaration is
made.
7
In case any declaration(s) in Form No. 15G is filed before filing this declaration during the previous year, mention the total number of such Form No. 15G filed along with
the aggregate amount of income for which said declaration(s) have been filed.
8
Mention the distinctive number of shares, account number of term deposit, recurring deposit, National Savings Schemes, life insurance policy number, employee code,
etc.
9
Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
10
Before signing the declaration/verification, the declarant should satisfy himself that the information furnished in this form is true, correct and complete in all respects. Any
person making a false statement in the declaration shall be liable to prosecution under section 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 imprisonment which shall not be less than six 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 three months but which may extend to two years and with fine.
11
The person responsible for paying the income referred to in column 16 of Part I shall allot a unique identification number to all the Form No. 15G received by him during
a quarter of the financial year and report this reference number along with the particulars prescribed in rule 31A(4)(vii) of the Income-tax Rules, 1962 in the TDS statement
furnished for the same quarter. In case the person has also received Form No.15H during the same quarter, please allot separate series of serial number for Form No.15G
and Form No.15H.
12
The person responsible for paying the income referred to in column 16 of Part I shall not accept the declaration where the amount of income of the nature referred to in
sub-section (1) or sub-section (1A) of section 197A or the aggregate of the 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. For deciding the eligibility, he is required to verify income or the
aggregate amount of incomes, as the case may be, reported by the declarant in columns 16 and 18.

Disclaimer
1. Form 15G is to be filled only for Individuals less than 60 years (if >=60 yrs then fill Form 15H), Proprietorship, Society, Associations
of Persons, Trust, HUF etc
2. TDS waiver will not be marked if PAN details are not updated on the Bank's records
3. TDS waiver will be marked from the date of submission of this form
4. TDS which has already been deducted will not be refunded back and which can be sought from Income Tax department
5. A fresh Form 15G needs to be submitted in each new Financial Year within the start of the Financial Year.
6. Form 15G needs to be submitted in Triplicate
7. Form 15G needs to be submitted for every fixed Deposits booked with bank
8. The Bank shall not be liable for any consequences or loss arising due to delay or non or wrong submission of Form 15G
9. I/We fully understand that wrong quoting of PAN may result in penal consequences under section 272B of Income Tax act 1961 and
the bank is not responsible for any consequences arising due wrong quoting of PAN
Bar Code : PAN :
B P L F 1 1 0 0 0 0 1

"FORM NO. 15G

[See section 197A(1), 197A(1A) and rule 29C]

Declaration under section 197A (1) and section 197A(1A) to be made by an individual or a person (not being
a company or firm) claiming certain incomes without deduction of tax.
PART I
1. Name of Assessee (Declarant) 2. PAN of the Assessee1

3. Status2 4. Previous year(P.Y.)3 5. Residential Status4

(for which declaration is being made)
6. Flat/Door/Block No. 7. Name of Premises 8. Road/Street/Lane 9. Area/Locality

10. Town/City/District 11. State 12. PIN 13. Email

14. Telephone No. (with STD 15 (a) Whether assessed to tax under the Yes No
Code) and Mobile No. Income-tax Act, 19615:
(b) If yes, latest assessment year for which assessed
16. Estimated income for which this declaration is made 17. Estimated total income of the P.Y. in which
income mentioned in column 16 to be included6

18. Details of Form No. 15G other than this form filed during the previous year, if any7
Total No. of Form No. 15G filed Aggregate amount of income for which Form No.15G filed

19. Details of income for which the declaration is filed

Sl. Identification number of 8
relevant Nature of income Section under which tax Amount of income
No. investment/account, etc. is deductible

RMTL
HDFC BANK LTD
© CUST ID:
© FD/RD NO :
© FD/RD NO :

9333 /05.11.2015
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :
© FD/RD NO :

……………………………………….
Signature of the Declarant9

Branch
Seal with
Sign &
Date
 Declaration/Verification10
*I/We………………………………do hereby declare that to the best of *my/our knowledge and belief what is
stated above is correct, complete and is truly stated. *I/We declare that the incomes referred to in this form are not
includible in the total income of any other person under sections 60 to 64 of the Income-tax Act, 1961. *I/We further
declare that the tax *on my/our estimated total income including *income/incomes referred to in column 16 *and
aggregate amount of *income/incomes referred to in column 18 computed in accordance with the provisions of the
Income-tax Act, 1961, for the previous year ending on .................... relevant to the assessment year ..................will
be nil. *I/We also declare that *my/our *income/incomes referred to in column 16 *and the aggregate amount of
*income/incomes referred to in column 18 for the previous year ending on .................... relevant to the assessment
year .................. will not exceed the maximum amount which is not chargeable to income-tax.

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

Signature of the Declarant9
Date: ………………………………………………..

PART II
[To be filled by the person responsible for paying the income referred to in column 16 of Part I]
1. Name of the person responsible for paying 2. Unique Identification No.11

3. PAN of the person 4. Complete Address 5. TAN of the person responsible for paying
responsible for paying

6. Email 7. Telephone No. (with STD Code) and Mobile No. 8. Amount of income paid12

9. Date on which Declaration is received 10. Date on which the income has been paid/credited
(DD/MM/YYYY) (DD/MM/YYYY)

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

Signature of the person responsible for paying
Date: ……………………………………………….. the income referred to in column 16 of Part I
Notes:
*Delete whichever is not applicable
1
As per provisions of section 206AA(2), the declaration under section 197A(1) or 197A(1A) shall be invalid if the declarant fails to furnish his valid Permanent Account
Number (PAN).
2
Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a firm) under section 197A(1A).
3
The financial year to which the income pertains.
4
Please mention the residential status as per the provisions of section 6 of the Income-tax Act, 1961.
5
Please mention “Yes” if assessed to tax under the provisions of Income-tax Act, 1961 for any of the assessment year out of six assessment years preceding the year in
which the declaration is filed.
6
Please mention the amount of estimated total income of the previous year for which the declaration is filed including the amount of income for which this declaration is
made.
7
In case any declaration(s) in Form No. 15G is filed before filing this declaration during the previous year, mention the total number of such Form No. 15G filed along with
the aggregate amount of income for which said declaration(s) have been filed.
8
Mention the distinctive number of shares, account number of term deposit, recurring deposit, National Savings Schemes, life insurance policy number, employee code,
etc.
9
Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
10
Before signing the declaration/verification, the declarant should satisfy himself that the information furnished in this form is true, correct and complete in all respects. Any
person making a false statement in the declaration shall be liable to prosecution under section 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 imprisonment which shall not be less than six 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 three months but which may extend to two years and with fine.
11
The person responsible for paying the income referred to in column 16 of Part I shall allot a unique identification number to all the Form No. 15G received by him during
a quarter of the financial year and report this reference number along with the particulars prescribed in rule 31A(4)(vii) of the Income-tax Rules, 1962 in the TDS statement
furnished for the same quarter. In case the person has also received Form No.15H during the same quarter, please allot separate series of serial number for Form No.15G
and Form No.15H.
12
The person responsible for paying the income referred to in column 16 of Part I shall not accept the declaration where the amount of income of the nature referred to in
sub-section (1) or sub-section (1A) of section 197A or the aggregate of the 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. For deciding the eligibility, he is required to verify income or the
aggregate amount of incomes, as the case may be, reported by the declarant in columns 16 and 18.

Disclaimer
1. Form 15G is to be filled only for Individuals less than 60 years (if >=60 yrs then fill Form 15H), Proprietorship, Society, Associations
of Persons, Trust, HUF etc
2. TDS waiver will not be marked if PAN details are not updated on the Bank's records
3. TDS waiver will be marked from the date of submission of this form
4. TDS which has already been deducted will not be refunded back and which can be sought from Income Tax department
5. A fresh Form 15G needs to be submitted in each new Financial Year within the start of the Financial Year.
6. Form 15G needs to be submitted in Triplicate
7. Form 15G needs to be submitted for every fixed Deposits booked with bank
8. The Bank shall not be liable for any consequences or loss arising due to delay or non or wrong submission of Form 15G
9. I/We fully understand that wrong quoting of PAN may result in penal consequences under section 272B of Income Tax act 1961 and
the bank is not responsible for any consequences arising due wrong quoting of PAN