Company/Firm 120 sambhu nagar,

ABC COMPANY Adddress

Name & Address mumbai

Tan BOMB2783L PAN AA

Name of Owner Rahul dravid Designation Properitor

Sr. No. Name Father's PAN Address Town/City PIN

Name

1 Bhushan Brij Lal aa 115, sector 3 Mumbai 400725

2 nitin ved prakashmmmm
3 kishore sss aaa
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 20 sambhu nagar,
Financial Year
mumbai

2013-14

roperitor

State Loan Amount Date on Date of Amount of Rate of

which Credit of Interest Interest
Amount Interest
given On
Loan

Maharastra 200000 31-3-2012 1/4/2013 50000 12

mmkm
n njkn
Certificate no. 1
FORM NO. 15G
[See section 197A(1), 197A(1A) and rule 29C]
Declaration under section 197A(1) and section 197A(1A) of the Incometax Act, 1961 to be made by an individual or a
person (not being a company or firm) claiming certain receipts without deduction of tax.
PART - I
1. Name of Assessee (Declareant) 2. PAN of the Assessee
Bhushan aa
3. Assessment Year 2013-14
4. Flat/Door/Block No. 5. Name of Premises 6. #Status
7. Assessed in which
115, sector 3 Ward/Circle
8. Road/Street/Lane 9. Area/Locality 10. AO Code(under whom
assessed last time
Area Code AO Type Range CodeAO No.
11. Town/City/District 12. State
Maharastra 14. Last Assessment Year in
Mumbai which assessed
13. PIN 400725
15. Email 16. Telephone No. 17. Present Ward/Circle
18. Residential Status
19. Name of Business/Occupation 20. Present AO Code (if
not same as above
21. Jurisdictional Chief Commissioner of Incometax or Commissioner Area Code AO Type Range CodeAO No.
of Incometax(if not assessed to income tax earlier)
22. Estimated total income from the sources mentioned below: (Please tick the relevant box)
Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Income form units referred to in Schedule IV
The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred
to in ScheduleV
23. Estimated total income of the previous year in which income mentioned in Column 22 is to be
included

24. Details of investments in respect of which the declaration is being made:

SCHEDULEI
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
No. of Class of shares & Total value Distinctive numbers Date(s) on which the shares
shares face value of each of shares of the shares were acquired by the
share declarant(dd/mm/yyyy)
---------- N. A. -----------

SCHEDULEII
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Amount of Date(s) of Date(s)on which the securitues
securities securities securities securities were acquired by the
(dd/mm/yyyy) declarant(dd/mm/yyyy)
---------- N. A. -----------

SCHEDULEIII
(Details of the sums given by the declarant on interest)
Name and address of the Amount of Date on which the sums Period for which Rate
person to whom the sums are sums given were given on sums were of
given on interest on interest Interest(dd/mm/yyyy) given on interest interest
ABC COMPANY 200000 31-3-2012 2013-14 12
120 sambhu nagar, mumbai
 SCHEDULE IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the Number of Class of units and Distinctive numbers Income
mutual fund units face value of each of in respect
unit unit of units
---------- N. A. -----------

SCHEDULEV
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account Date on which the account The amount of
under the National Savings Scheme was opened(dd/mm/yyyy) withdrawal from the
is maintained and the account number account
---------- N. A. -----------

**Signature of the Declarant

Declaration/Verification

*I/ We Bhushan 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 u/s 60 to 64 of the Incometax Act,
1961. *I/We further, declare that the tax *on my/our estimated total income, including *income/incomes referred to
in Column 22 above, computed in accordance with the provisions of the Incometax Act, 1961, for the previous year
ending on 3/31/2013 relevant to the assessment year 2013-14 will be nil. *I/We also, declare that
*my/our *income/incomes referred to in Column 22 for the previous year ending on 3/31/2013 relevant to
the assessment year 2013-14 will not exceed the maximum amount which is not chargable to income tax.

Place : Mumbai
Date : **Signature of the Declarant

PART - II
[For use by the person to whom the declaration is furnished]
1. Name of the person responsible for paying the income referred to in 2. PAN of the person indicated in Column 1 of
Column 22 of Part I Part II
ABC COMPANY AA
3. Complete Address 4. TAN of the person indicated in
120 sambhu nagar, mumbai Column 1 of Part II
BOMB2783L
5. Email 6. Telephone No. 7. Status Properitor

8. Date on which Declaration is 9. Period in respect of which the 10. Amount of income 11. Date on which the
Furnished dividend has been declared or the paid income has been paid/
income has been paid/credited credited(dd/mm/yyyy)
50000

2013-14 1/4/2013
12. Date of declaration, distribution or payment of dividend/withdrawal 13. Account Number of National Saving Scheme from which withdrawal has
under the National Savings Scheme(dd/mm/yyyy) been made ---- N. A. -----
---- N. A. -----
Forwarded to the Chief Commissioner or Commissioner of Incometax

Place :
Date : Signature of the person responsible for
 paying the income referred to in
download from-www.taxalertindia.com Column 22 of Part I

http://taxalertindia.com http://taxalertindia.com
download from-www.taxalertindia.com
 FORM NO. 15H
[See section
Declaration under section 197A(1C) of the197A(1C),
Incometax197A(1A)
Act, 1961 and
to berule
made29C(1A)]
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 (Declareant) 2. PAN of the Assessee
3. Age
4. Assessment Year 2013-14
5. Flat/Door/Block No. 6. Name of Premises 7. Assessed in which Ward/Circle
10. AO Code(under whom
8. Road/Street/Lane 9. Area/Locality assessed last time
Area Code AO Type Range CodeAO No.
11. Town/City/District 12. State
14. Last Assessment Year in
13. PIN which assessed
15. Email 16. Telephone No. 17. Present Ward/Circle

18. Name of Business/Occupation 19. Present AO Code (if

not same as above
20. Jurisdictional Chief Commissioner of Incometax or Commissioner Area Code AO Type Range CodeAO No.
of Incometax(if not assessed to income tax earlier)
21. Estimated total income from the sources mentioned below: (Please tick the relevant box)
Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Income form2 units
The amount of withdrawal referred to in clause (a) of subsection referred
of section to inreferred
80CCA Scheduleto IV
in
22. Estimated total income of the previous year in which income mentioned in Column 21 is to be V
Schedule
included

23. Details of investments in respect of which the declaration is being made:

SCHEDULEI
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
No. of Class of shares & Total value Distinctive numbers Date(s) on which the shares
shares face value of each of shares of the shares were acquired by the
share declarant(dd/mm/yyyy)
---------- N. A. -----------

SCHEDULEII
(Details of the securities held in the name of declarant and beneficially owned by him)
Description of Number of Amount of Date(s) of Date(s)on which the securitues
securities securities securities securities were acquired by the
(dd/mm/yyyy) declarant(dd/mm/yyyy)
---------- N. A. -----------

SCHEDULEIII
(Details of the sums given by the declarant on interest)
 Name and address of the Amount of Date on which the sums Period for which Rate
person to whom the sums are sums given were given on sums were of
given on interest on interest Interest(dd/mm/yyyy) given on interest interest

SCHEDULE IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the Number of Class of units and Distinctive number Income
mutual fund units face value of each of in respect
unit units of units
---------- N. A. -----------

SCHEDULEV
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account Date on which the account The amount of
under the National Savings Scheme was opened(dd/mm/yyyy) withdrawal from the
is maintained and the account number account
---------- N. A. -----------

**Signature of the Declarant

Declaration/Verification

*I/ We 0 do hereby declare that I am resident in India

within the meaning of section 6 of the Incometax 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 Incometax Act, 1961. I further, declare
that the tax my estimated total income,including income/income referred to in column 21 computed in accordance
with the provisions of the Incometax Act, 1961, for the previous year ending on 3/31/2013 relevant to the
relevant to the assessment year 2013-14 will be nil.

Place : AHMEDABAD
Date : **Signature of the Declarant

PART - II
[For use by
1. Name of the person responsible for the person
paying to whom
the income thetodeclaration
referred in is furnished]
Column 21 of Part I 2. PAN of the person indicated in Column 1 of
Part II
3. Complete Address 4. TAN of the person indicated in
Column 1 of Part II

5. Email 6. Telephone No. 7. Status

8. Date on which Declaration is 9. Period in respect of which the 10. Amount of income 11. Date on which the
Furnished dividend has been declared or the paid income has been paid/
income has been paid/credited credited(dd/mm/yyyy)

12. Date of declaration, distribution or payment of dividend/withdrawal 13. Account Number of National Saving Scheme from which withdrawal has
under the National Savings Scheme(dd/mm/yyyy) ---- been made ---- N. A. ----
N. A. ----

Forwarded to the Chief Commissioner or Commissioner of Incometax

Place :
Date : Signature of the person responsible for
paying the income referred to in
Column 21 of Part I
f the age of sixty

2013-14
rcle

AO No.

AO No.

e relevant box)

im)
ch the shares
red by the
d/mm/yyyy)

)
the securitues
red by the
d/mm/yyyy)
 Rate
of
interest

him)
Income
in respect
of units

he amount of
drawal from the
account

the Declarant

resident in India
my knowledge
o in this form
urther, declare
n accordance
relevant to the

the Declarant

d in Column 1 of
d in

ate on which the

e has been paid/
ed(dd/mm/yyyy)

which withdrawal has

----

ponsible for
erred to in
art I