FORM NO. 15H[See section 197A (1C) and rule 29C]
Declaration under section 197A(1C) to be made by an individual who is of the age of sixty years ormore claiming certain incomes without deduction of tax.

PART I
1. Name of Assessee (Declarant)

4. Previous year(P.Y.)3 (for which
declaration is being made)7. Road/Street/Lane
11. PIN

2. PAN of the Assessee1

5. Flat/Door/Block No.

8. Area/Locality

6. Name of Premises

9. Town/City/District

12. Email3. Date of Birth2(DD/MM/YYYY)

10. State

13. Telephone No. (with STD Code) andMobile No.

14 (a) Whether assessed to tax under theIncome tax Act4:

YesNo(b) If yes, latest assessment year for which assessed
15. Estimated income for which this declaration is
16. Estimated total income of the P.Y. in which
madeincome mentioned in column 15 to be included5
17. Details of Form No.15H other than this form filed for the previous year, if any6
Total No. of Form No.15H filed

Aggregate amount of income for which Form No.15H
filed

18. Details of income for which the declaration is filed
Sl.
No.

Identification number of
relevant investment/account,
etc.7

Nature of income

Section under whichtax is deductible

Amount of income………………………………….
Signature of the Declarant

Declaration/Verification8
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 myknowledge 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 under sections 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 15 *and aggregate amount of *income/incomes referred to incolumn 17 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 DeclarantPlace: ………………………
Date: ………………………

PART IIII
[To be filled by the person responsible for paying the income referred to in column 15 of Part I]
1. Name of the person responsible for paying

2. Unique Identification No.9

3. PAN of the person responsiblefor paying

4. Complete Address

5. TAN of the person responsiblefor paying

6. Email

7. Telephone No. (with STDCode) and Mobile No.

8. Amount of income paid10

9. Date on which Declaration is received(DD/MM/YYYY)

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 15 of Part I
Place: ………………..
Date: …………………
*Delete whichever is not applicable.
section 206AA(2), the declaration under section 197A(1C) shall be invalid if thedeclarant fails to furnish his valid Permanent Account Number (PAN).
2Declaration can be furnished by a resident individual who is of the age of 60 years or more at any time
during the previous year.
3The financial year to which the income pertains.
4 Please mention “Yes” if assessed to tax under the provisions of Income-tax Act, 1961 for any of theassessment year out of six assessment years preceding the year in which the declaration is filed.
5Please mention the amount of estimated total income of the previous year for which the declaration isfiled including the amount of income for which this declaration is made.
1As per provisions of

6Incase any declaration(s) in Form No. 15H is filed before filing this declaration during theprevious year, mention the total number of such Form No. 15H filed along with the aggregate
amount of income for which said declaration(s) have been filed.
7Mention the distinctive number of shares, account number of term deposit, recurring deposit,
National Savings Schemes, life insurance policy number, employee code, etc.
8Before signing the declaration/verification, the declarant should satisfy himself that theinformation 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 sevenyears 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.
9The person responsible for paying the income referred to in column 15 of Part I shall allot aunique identification number to all the Form No. 15H received by him during a quarter of thefinancial 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.15G during the same quarter, please allot
separate series of serial number for Form No.15H and Form No.15G.
10The person responsible for paying the income referred to in column 15 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 amountwhich is not chargeable to tax after allowing for deduction(s) under Chapter VI-A, if any, or set
off of loss, if any, under the head “income from house property” for which the declarant iseligible. For deciding the eligibility, he is required to verify income or the aggregate amount ofincomes, as the case may be, reported by the declarant in columns 15 and 17.