"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.
1. Name of Assessee (Declarant)
2. PAN of the Assessee1
3. Status2
4. Previous year (P.Y)3
(for which declaration is being
made)
5. Residential Status4
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 Code)
and Mobile No
15. (a) Whether assessed to tax under the
Income-tax Act, 19615
Yes
No
(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 any 7
Total No. of Form No. 15G filed
Aggregate amount of income for which Form No. 15G filed
19. Details of income for which declaration is filed
SI
Identification number of relevant
Nature of income
No investment/account etc.8
Section under which tax
is deductible
Amount of income
PART I
..
Signature of the Declarant9
10
Declaration/Verification
*I/Wedo 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 Declarant
Date: .
Kotak Mahindra Bank Ltd. CIN: L65110MH1985PLC03813 Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra
(E), Mumbai - 400 051. www.kotak.com
KMBL/Dec-2015/V1.0 1
PART II
[To be filled by the person responsible for paying the income referred to in column 16 of Part I]
1. Name of person responsible for paying
2. Unique Identification No.11
3. PAN of the person
responsible for paying
5. TAN of the person responsible for
paying
4. Complete Address
6. Email
7. Telephone No. (with STD
Code) and Mobile No.
9. Date on which Declaration is received (DD/MM/YYYY)
Place:.
Date:..
8. Amount of income paid12
10. Date on which the income has been
paid/credited (DD/MM/YYYY)
Signature of the person responsible for paying
The income referred to in column 16 of Part I
*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.
Kotak Mahindra Bank Ltd. CIN: L65110MH1985PLC03813 Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra
(E), Mumbai - 400 051. www.kotak.com
KMBL/Dec-2015/V1.0 1
