FORM No.
15B
[See rule 30A(2)]
Form of declaration to be made by the registered shareholder and by the
person claiming credit where the dividend on the share is
assessable as the income of such other person
I/We hereby declare that dividends(s), as per details shown in columns 4 to 7 of
the Table hereinbelow*,on the share(s), specified in column 3 theeof, registered
my/our name(s)
in _____________________________________________________________________________
the name of ____________________________________________________________________
[the bank/company, etc.]
was collected by me/us ___________________________________________. on behalf of
[name of the bank/company, etc.]
___________________________ who is/which is beneficially entitled to receive the
[name and address]
income by way of dividend. Particulars of the tax deducted at source from the
dividend(s) mentioned hereinabove, as shown in the certificate of deduction of
tax under section 203 issued in my/our name ____________________________________
[name of the bank/company,etc.]
are given in columns 8 to 10 of the Table hereinbelow.
I/We further declare that I/we _________________________________________________
[the bank/company, etc.]
has/have not claimed any credit under section 199, nor has any credit under the
section been allowed to me/us __________________________________________________
[the bank/company, etc.]
for the tax deducted from the dividend(s) on these shares.
I/We also undertake that I/We __________________________________________________
[the bank/company, etc.]
shall not claim any credit under section 199 for the tax deducted at source from
the dividend(s) on these shares.
Date : _________. ___________________
Signature of the shareholder
___________________
Address ___________________
TABLE GIVING DETAILS OF DIVIDENDS, SHARES, ETC.
________________________________________________________________________________
S. Name of No.,description Date of Date of Period for Amount
No. company and face value declaration receipt of which divi- of
paying the of shares of the dividend dend dividend
dividend dividend declared
________________________________________________________________________________
1 2. 3 4 5 6 7
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Tax deduction under section Net Particulars of certificate
194 of the Income-tax Act, 1961 Amount of certificate of deductiont
_______________________________ Received of tax under section 203
IT SC Total
_______________________________
8 9 10 11 12
________________________________________________________________________________
________________________________________________________________________________
I/We hereby declare that the dividend(s), as per details shown in columns 4 to 7
of the above Table on the share(s) specified in column 3 thereof, is/are
my/our income
assessable as _________________ ___________________________________________
the income of the [name of the bank/company, etc.]
At the time when the dividend on the above-mentioned share(s) was declared/
credited/paid, these shares were registered in the name(s) of __________________
_______________________________________________________________ and the dividend
[name and address]
on my/our behalf
thereon was collected by the said ---------------------------------------------
on behalf of the bank/company, etc.
I/We, therefore, request that for the reasons given hereunder the credit in
respect of the tax deducted at source from the dividend mentioned above should
be given to me/us
-----------------------
the bank/company, etc.
___________________________
___________________________
___________________________
[Reasons to be stated]
Place : __________
________________________
Date : __________ Signature of the person claiming credit
