"FORM NO. 15H
[See section 197A(1C) and rule 29C(1A)]
Declaration under section 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 deduction of tax
PART‐I

1. Name of Assessee (Declarant)
10. AO Code(under whom assessed last
time)
Area Code
AO No.
19. Present AO Code (if not same as above)
AO Type
5. Flat/Door/Block No. 6. Name of Premises
2. PAN of the Assessee
18. Name of Business/Occupation
15. Email 16. Telephone No. (with STD Code) and Mobile No.
20. Jurisdictional Chief Commissioner of Income tax or Commissioner of Income tax(if not assessed
to Income tax earlier)
11. Town/City/District
Range Code AO No.
Income from units referred to in Schedule IV
AO Type
Area Code
21. Estimated total income from the sources mentioned below
Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
(Please tick the relevant box)
SCHEDULE V
Name and address of the
person to whom the sums are
given on interest
SCHEDULE II
Particulars of the Post Office where the account under the National
Savings Scheme is maintained and the account number
Date on which the account was
opened(dd/mm/yyyy)
The amount of
withdrawal from the
account
Name and address of the
mutual fund
SCHEDULE III
(Details of the sums given by the declarant on interest)
SCHEDULEIV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
The amount of withdrawal referred to in clause (a) of subsection 2 of section 80CCA referred to in Schedule V
22. Estimated total income of the previous year in which income mentioned in Column 21 is to be included (Details of shares, which stand in the name of the declarant and beneficially owned by him)
23.Details of investments in respect of which the declaration is being made:
Number of securities
Description of
securities
SCHEDULE I
Date(s) of
securities
(dd/mm/yyyy)
Date(s) on which the securities were acquired by the
declarant(dd/mm/yyyy)
Class of shares &
face value of each
share
Distinctive numbers of
the shares
Date(s) on which the shares were acquired by the
declarant(dd/mm/yyyy)
Class of units and face
value of each unit
Distinctive number of units
Income in respect of
units
Period for which such sums were
given on interest
Date on which the sums were
given on interest(dd/mm/yyyy)
(Details of the securities held in the name of declarant and beneficially owned by him)
Place:
Date:
Place:
Date:
Notes:
1.
2.
3.
i)
ii)
4.
Before signing the verification , the declarant should satisfy himself that the information furnished in the declaration is true, correct and complete in all
respects. Any person making a false statement in the declaration shall be liable to prosecution under 277 of the Income tax Act, 1961 and on conviction be
punishable
[For use by the person to whom the declaration is furnished]
Delete whichever is not applicable.
The person responsible for paying the income referred to in column 21 of Part I shall not accept the declaration where the amount of income of the nature
referred to in section 197A(1C) 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 and deduction(s) under Chapter VIA, if any, for which the
declarant is eligible.";
In a case where tax sought to 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;
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.
PART II
2. PAN of the person indicated in Column 1 of Part II
4. TAN of the person indicated in Column 1 of Part II
Forwarded to the Chief Commissioner or Commissioner of Income tax…………………………………………………………
………………………………………………..
5. Email
The declaration should be furnished in duplicate.
6. Telephone No. (with STD Code) and Mobile No.
7. Status
Declaration/Verification
Signature of the Declarant
………………………………………………..
………………………………………………..
……………………………………………….
Signature of the person responsible for
paying the income referred to in Column
21 of Part I
…………………………………………………….
…………………………………………………………….
3. Complete Address
I……………………………….do hereby declare that I am resident in India within the meaning of section 6 of the Income tax Act, 1961. I also, hereby declare that to
the best of my knowledge and belief what is stated above is 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 u/s 60 to 64 of the Income tax Act, 1961. I further, declare that the tax on my estimated total income,
including income/incomes referred to in column 21 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.
…………………………………………………………….
Signature of the Declarant
12. Date of declaration, distribution or payment of
dividend/withdrawal under the National Savings
Scheme(dd/mm/yyyy)
13. Account number of National Savings Scheme from which withdrawal has been made
8. Date on which declaration is furnished
(dd/mm/yyyy)
9. Period in respect of which the dividend has been
declared or the income has been paid/credited
10. Amount of income paid 11. Date on which the
income has been paid /
credited(dd/mm/yyyy)
1. Name of the person responsible for paying the income referred to in Column 21 of Part I