"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) 2. PAN of the Assessee
3. Age 4. Assessment Year                                        
(for which declaration is being made)
5. Flat/Door/Block No. 6. Name of Premises 7. Assessed in which Ward/Circle
8. Road/Street/Lane 9. Area/Locality 10. AO Code(under whom assessed last 
time)
Area Code AO Type Range Code AO No.
11. Town/City/District 12. State
13. PIN
14. Last Assessment Year in which assessed
15. Email  16. Telephone No. (with STD Code) and Mobile No. 17. Present Ward/Circle

18. Name of Business/Occupation 19. Present AO Code   (if not same as above)
20. Jurisdictional Chief Commissioner of Income‐tax or Commissioner of Income‐tax(if not assessed  Area Code AO Type Range Code AO No.
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 from units referred to in Schedule  IV
The amount of withdrawal referred to in clause (a) of sub‐section 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

23.Details of investments in respect of which the declaration is being made:
SCHEDULE‐I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
Class of shares & 
No. of  Total value  Distinctive numbers of  Date(s) on which the shares were acquired by the 
face value of each 
shares of shares the shares declarant(dd/mm/yyyy)
share

SCHEDULE‐II
(Details of the securities held in the name of  declarant and beneficially owned by him)
Date(s) of 
Description of  Amount of  Date(s) on which the securities were acquired by the 
Number of securities securities 
securities securities declarant(dd/mm/yyyy)
(dd/mm/yyyy)

SCHEDULE‐III
(Details of the sums given by the  declarant on interest)
Name and address of the  Amount of  
Date on which the sums were  Period for which such sums were  Rate of 
person to whom the sums are  sums given 
given on interest(dd/mm/yyyy) given on interest interest
given on interest on 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 face  Income in respect of 
Distinctive number of units
mutual fund units value of each unit units

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

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 …………………………………………………………….
Signature of the Declarant
Declaration/Verification

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.
Place: ……………………………………………….. …………………………………………………………….
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 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. (with STD Code) and Mobile No.
7. Status
8. Date on which declaration is furnished  9. Period in respect of which the dividend has been  10. Amount of income paid 11. Date on which the 
(dd/mm/yyyy) declared or the  income has been paid/credited income has been paid / 
credited(dd/mm/yyyy)
12. Date of declaration, distribution or payment of  13. Account number of National Savings Scheme from which withdrawal has been made
dividend/withdrawal under the National Savings 
Scheme(dd/mm/yyyy)

Forwarded to the Chief Commissioner or Commissioner of Income‐tax…………………………………………………………

Place: ……………………………………………….. …………………………………………………….

Date: ……………………………………………….
Signature of the person responsible for
paying the income referred to in Column
21 of Part I

Notes:
1. The declaration should be furnished in duplicate.
2. *Delete whichever is not applicable.
3. 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 statementin the declaration shall be liable to prosecution under 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 6 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 3 months but which may extend to  two years and with fine.
4. 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 VI‐A, if any, for which the
declarant is eligible.";

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