FORM NO. 15G[See section 197A (1), 197A (1A) and rule 29C]
Declaration under section 197A (1) and section 197A (1A) to be made by an individual or a person(not being a company or firm) claiming certain incomes without deduction of tax.

PART I
1. Name of Assessee (Declarant)
3. Status2

2. PAN of the Assessee1
4. Previous year(P.Y.)3(for which declaration is being made)5. Residential Status4

6. Flat/Door/Block No.

7. Name of Premises

8. Road/Street/Lane

9. Area/Locality

10. Town/City/District

11. State

12. PIN

13. Email14. Telephone No. (with STDCode) and Mobile No.

15 (a) Whether assessed to tax under the
Income-tax Act, 19615:

YesNo(b) If yes, latest assessment year for which assessed
16. Estimated income for which this declaration
is made17. Estimated total income of the P.Y. in which
income mentioned in column 16 to be included6

18. Details of Form No. 15G other than this form filed during the previous year, if any7
Total No. of Form No. 15G filed

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

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

Identification number of relevant
investment/account, etc.8

Nature of income

Section under which
taxis deductible

Amount of income………………………………….
Signature of the Declarant9

Declaration/Verification10*I/We………………………………………………………………….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 declarethat the incomes referred to in this form are not includible in the total income of any other person undersections 60 to 64 of the Income-tax Act, 1961. *I/We further declare that the tax *on my/our estimatedtotal income including *income/incomes referred to in column 16 *and aggregate amount of*income/incomes referred to in column 18 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. *I/We also declare that *my/our *income/incomes referred to in column 16 *and the aggregate
amount of *income/incomes referred to in column 18 for the previous year ending on ....................
relevant to the assessment year .................. will not exceed the maximum amount which is not
chargeable to income-tax.
………………………………….
Signature of the Declarant9
Place: …………………
Date: …………………

PART II[To be filled by the person responsible for paying the income referred to in column 16 of Part I]
1. Name of the person responsible for paying
3. PAN of the person
responsible for paying
6. Email

2. Unique Identification No.11

4. Complete Address

5. TAN of the person responsiblefor paying

7. Telephone No. (with STD Code) and Mobile No.

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

8. Amount of income
paid12

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 16 of Part I
Place: ………………
Date: ………………
*Delete whichever is not applicable.
1As

per provisions of section 206AA(2), the declaration under section 197A(1) or 197A(1A) shall be
invalid if the declarant fails to furnish his valid Permanent Account Number (PAN).

2Declarationcan be furnished by an individual under section 197A (1) and a person (other than acompany or a firm) under section 197A(1A).

3The financial year to which the income pertains.
4Please mention the residential status as per the provisions of section 6 of the Income-tax Act, 1961.
5 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.
6Please mention the amount of estimated total income of the previous year for which the declaration is
filed including the amount of income for which this declaration is made.
7In case any declaration(s) in Form No. 15G is filed before filing this declaration during the previous year,
mention the total number of such Form No.15G filed along with the aggregate amount of income for which
said declaration(s) have been filed.
8Mention the distinctive number of shares, account number of term deposit, recurring deposit, National

Savings Schemes, life insurance policy number, employee code, etc.
9Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
10Beforesigning the declaration/verification, the declarant should satisfy himself that the information
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 seven years andwith 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.

11The person responsible for paying the income referred to in column 16 of Part I shall allot a unique

identification number to all the Form No. 15G received by him during a quarter of the financial year andreport 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.15H during the same quarter, please allot separate series of serial number for Form No.15G andForm No.15H.
12The person responsible for paying the income referred to in column 16 of Part I shall not accept thedeclaration where the amount of income of the nature referred to in sub-section (1) or sub-section (1A) ofsection 197A or the aggregate of the amounts of such income credited or paid or likely to be credited orpaid during the previous year in which such income is to be included exceeds the maximum amountwhich is not chargeable to tax. For deciding the eligibility, he is required to verify income or the aggregate
amount of incomes, as the case may be, reported by the declarant in columns 16 and 18.