FORM NO.15H (See section TO7AITC) snd rulo29C(14) Declaration under secon 197A|1C) ofthe Income Act, 1961 0 Be made by an individual who ie ofthe age of ey yars ot ‘more claiming conan cepts without deduction of tx. PART-1 fi. Name of Assessee (Declarant) i. PAN of te Assossee ia Age {Assessment Year for which declaration is being made) i5 FsuDooriBlock No. I. Name of Promise 1. Aesaseed in wich WariCvcle ig RoadiStreattane 18. ArealLocaliy a ee eat eee ‘| besstoas [ine Pre CaS Wr It. TowniGiy/Distiet 2. State is. FN is, Email 6. Telephone No. wih STO [code) and Mobile No. 8, Name of Business/Occupation 1a Pasank AO Gade (nat sme we above) i Jaredictonel Chief Commissioner of Income-tox or Commissions lof income-taxlf not assessed to Income-tax earlier) li. Eetimated total income from the sources mentionod below ‘Pica Wak th elvan bos ‘Dividend om thes ofred wo Sahel Titres on scuies veered to Wo Sele Tneome om units eared toh Seheaue qooo00 “The oncunt of wiharawal refered We in causa (a) ot zub seaion 7 af eacion BICCA refered ein Soha] Bz Esimatod total income of he previous year ia whch come rreniored in Colm 71 isto be ineaded Za0urals of vestments in espect of which the declaration is beng made: ‘SoHEOE tis of hares, wich standin te namo ofthe declarant and poefiaty owned by Nin) Naot | eee Sa | Tttvaueof shares | Disinctive manbers of te shares att) on wich the shares were aqui by he Sis an(sSmyyy) soveDuLea (Gets of he secures hl inte name of delrnt ond bap owned by Dt) ot sens esto of seis enka mea] Att fn ie loses on wich ie aes wee (Geom) fre ty the econ) scveDULEM {ete ofthe sums gen by ihe. eclant on terest Name ad ales oft peson to whom the suns | Amount ofsums given O° | Dye which hesums were [Period for whch such sams | Rat of nEEer = tivenonintrestddinmyy9)| wee givenon meres | irs ‘ScHEDULEWY ae of ho mutual fond units nas nts nana of devant and benelay owned by Ne Ta sg area" — Ra tne | Go Tur wa] tact rant tune [ = MTT‘SCHEDULEW (Detas of the withdrawal rade frm National Swings Scheme) lacs oft Fo:Oice whee he cu er the Nao Savings Scene | Date on wich he aout ie pad tar Oe ‘ronnie andthe cunt aber Secretly Me ME rz aa 1 Signature of the Declarant Declaration/Verification l. ..do hereby declare that | am resident in India within the meaning of section 6 of the Income-tax Act, 1961. | algo, hereby declare that to the best of my knowledge and belief what is stated above is ‘correct, complete and is truly stated and thet 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-tex Act, 1967. I further, declare thet the tax on my estimated total income, including tincomelincomes referred to in column 21 computed in accordance with the provisions of the Income-tax Act, 1981, for the previous year ending on relevant to the assessment year vawil be nil Place Date: > Signature of the Declarant sion is tunisned) PAI of the person Indicated in Column tof Part 7 Name ofthe person i ltPant 15 Complete Address {TAN af the person indicated in Column ¥ of Par I is Emad Telephone No. (with STO Cod and [Mobile No. fr Satu la Date on which declaration is furniched|s. Period in respect of which the 10, Amount of |17. Date on whieh the come laaummiveyy) Idividend has beon declared or the Kncome paid Inas been paid / income has been paid/recited lerediteaideirmmnyyyy! Nz, Date of declaration, dstbuton or {3, Account number of National Savings Scheme from which withdrawal has yen made [payment of dvidendivithdrawal under the National Savings Schematda/mmivv¥v) Forwarded to the Chief Commissioner of Commissioner of Income-Tax. Place: Date: Signature of the person responsible for paying the income referred to in Column 24 of Part! The declaration shoul be furnished In duplicate. TBelste whichever Is not epee Before signing the verification , the declerant should satisty himself that the information furnished in the declaration is tue, orreet and complete. in all respecte, Any person making a fake statementia the declaration shall be liable to prosecution under 277 of the Income-tax Act, 1981 and on conviction be punishable Ty In acase where tax sought to be evaded excaods twenty-five lakh rupees, with rigorous imprisonment which shell not be lass than 6 months ut which may extond to seven years and with fi 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 Par I shall not accept the declaration where the amount of Income of the nature referred to in section 197AI1C) or the aggregste of the amounts of such income credited or paid or likely to be credited or paid during the previous year in which such income Isto be included exceeds the maximum amount whichis not thargeable to tax and deduction\s) under Chapter VIA, if any, for which the declarant is eligible