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FORM NO. 15G

FORM NO. 15G

[See rule 29C(2)]

Declaration under section 197A(1) of the Income-tax Act, 1961, to be made

by an individual claiming receipt of dividend

without deduction of tax

I, ......................……………………….. son/daughter/wife of. .......................…………… resident

of…………………...................@ do hereby declare—

1. that I am a shareholder in...............……………………………… (name and address of the company);

2. that the shares in the said company, particulars of which are given below, stand in my name and are

beneficially owned by me, and the dividends therefrom are not includible in the total income of any

other person under sections 60 to 64 of the Income-tax Act, 1961:

No. of shares Class of shares Total face value Distinctive Date(s) on which

and face of shares numbers of the shares were

value of

 the shares acquired by

each share

 the declarant

3. that my present occupation is ................………………..;

4. that the tax on my estimated total income, including the dividends from the shares referred to in

paragraph 2 above, 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;

5. *that I have not been assessed to income-tax at any time in the past but I fall within the jurisdiction of

the Chief  Commissioner or Commissioner of Income-tax, ................;

OR

that I was last assessed to income-tax for the assessment year ....... …....... by the Assessing Officer

...................…….·Circle/Ward/District and the permanent account number allotted to me

is...................……..;

6. that I am resident in India within the meaning of section 6 of the Income-tax Act, 1961.

……………………………

Signature of the declarant

Verification

I, ...............……………………………………… do hereby declare that to the best of my knowledge and

belief what is stated above is correct, complete and is truly stated.

Verified today, the ...................day of..............,

Place ................

 ……………………………

Signature of the declarant



Notes:

1. @ Give complete postal address.

2. The declaration should be furnished in duplicate.

3. *Delete whichever is not applicable.

4. 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 statement in the

declaration shall be liable to prosecution under section 277 of the Income-tax Act. 1961, and on convic-

tion be punishable—

(i) in a case where tax sought to he evaded exceeds one lakh rupees, with rigorous imprisonment

which shall not be less than six 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 three months but

which may extend to three years and with fine.

[FOR USE BY THE PERSON TO WHOM THE DECLARATION IS FURNISHED]

1. Name and address of the company

2. Date on which the declaration was furnished by the declarant

3. Date of declaration, distribution or payment of dividends

4. Period in respect of which dividend has been declared

5. Amount of dividend paid

Forwarded to the Chief Commissioner or Commissioner of Income-tax..................

Place ......................

 ……………………………

Date ......................

 Signature of the principal

officer of the company


Download Word Document In English. (Rs.10/-)



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