INCOME-TAX RULES, 1962 Form No. 15H [See Section 197A(1C) and Rule 29C) Declaration under Section 197A(1C) to be made by an individual who is of the age of sixty years or more claiming certain incomes without deduction of tax. PART | 1. Name of Assessee (Declarant) 2 PAN ofthe Assessee’ 3. Date of Birth? (ODMMYYYY) 4. Previous year (P..) (for which 5. FlauDoorBlock No. 6, Name of Premises declaration is being made) . 7, RoadiStreetane 8. Area/Localty 9. Town/City/Dietrict 10, Stato 11.PIN 2. E-mei 13. Telephone No. (wth STD Code) and Mobile No. 14. (a) Whether assessed totax: Yes No (0) Ifyes. latest assessment year for which assessed 16, Estimated income for which this declaration ie made 16. Estimated total income of the PY. in which income | mentioned in Column 15 tobe included 17. Details of Form No. 15H other than this form filed for the previous year, if any* “Tolal No. of Form No. 15H filed [Aggregate amouint of income for which Form No. 15H filed 18. Details of income for which the dectaration is fled ‘SL identification number of relevant] Nature of income ‘Section under which taxis | Amount of income No._|investment/account, etc.” deductible peau Declaration/Verification’ Ue in do hereby declare that | am resident in India within the meaning of Section 6 of the Incometax Act, 1961. | also, hereby declare that to the best of my knowledge and beliet what is stated above i correct, complete and is truly stated and 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. | further, declare that the tax on my estimated total income including “income/incomes referred to in Column 15 and aggregate amount of *incomefincomes referred to in Column 17 computed in accordance with the provisions of the Income-tax Act, 1961, for the previous year ending on... ..-televantto the assessment year. willbe nil Place Date: Signature of the DeclarantPART-II {To be filed by the person responsible for paying the income referred to in Cokurnn 15 of Part 1, Name ofthe parson responsibie fr paying 2. Unique Kdertiicaton No * 3. PAN of the person respons paying fo for | 4 Complete Address 5. TAN of the person response for paying 6. E-mail Telephone No. (wth STD Code) and Mobile| 8. Amount of income paid No. 9, Date on which Declaration is received (OO/MM/YYYY), 10. Date on which the income has been paid‘credted |(OOMMYYYY) Place: Signature of the person responsible for paying Date : the income refered to in Column 15 of Pat “Delete whichever is not applicable, ‘As per provisions of Section 206AA(2), the declaration under section 197A(1C) shall be invalid ifthe deciarant fits to furnish is valid Permanent Account Number (PAN), ‘Declaration can be furnished by a resident individual whois ofthe age of 60 years or more at any time during the previous year. ‘The financial year to which the income pertains ‘Please mention Yes" if assessed to tax under the provisions of ncome-tax Act, 1961 for any of the assessment year out of six assessment years preceding the year in which the declaration i fled. ‘Please mention the amount of estimated total income of the previous year for which the declaration is filed including the amount of ‘income fot which this declaration is made, ‘tn case any deciaration(s) in Form No. 15H is filed before fling this declaration during the previous year, mention the total numberof such Form No. 15H filed along with the aggregate amount of income for which said declarations) have been filed. "Mention the distinctive numberof shares, account numberof term deposi, recurring deposit, National Savings Schemes, ife insurance Policy number, employee code, etc. ‘Before signing the declaration/verfication, the declarant should satisty himself thatthe information furished in tis form is tue, corect ‘and complete in all respects. Any person making a false statement in the declaratio. ‘be lable to prosecution under Section 277 of the Income-tax Act, 1961 and on conviction be punishable - (ijina case where tax sought to be evaded exceeds twenty-five lakh rupees, with igorous imprisonment which shall not be less than six months but which may extend to seven years and with fine; {iin any other case, with rigorous imprisonment which shall not be less than three months but which may extend fo two years and with fine. "The person responsible for paying the income referred to in Column 15 of Part | shall allot a unique identification number to all the Form No, 15H received by him during ¢ quarter of the financial year and report ths reference number along with the particulars prescribed in rule 31(4)(vil of the Income-tax Rules, 1962 in the TDS statement fumished for the same quarter. In case the person has also received Form No. 15G during the same quarter, please allot separate series of serial number for Form No. 15H and Form No. 15G. “The person responsible for paying the income referred to in Column 15 of Part | shall not accept the declaration where the amount cf income ofthe nature referred to in section 197A(1C) or the aggregate of the amounts of such income credited or pad 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 alr allowing for deduction(s) under Chapter VIA if any, of set off of oss, ifany, under the head “income from house property" for hich the declarant is eligible. For deciding the eligibility, he is required to very income or the aggregate amount of incomes, as the case may be, reported by the declarant in Columns 15 and 17.