FC,R,M hIO. 15 G{See seetion 19?A(1), 197A(lA) o,nd, rule 29C}

Oeclaration under section lS?A(l) and section 19?A(IA) of the Ineome.tax Act, 1961 to be made by anindividual or a person (not being o company or firm) claiming certain receipts without deduction of tax.

PART . I1. Name ol'Assessee {Doclarant) ?. PAN ofthe

Assessee

3. Assessment YearI tbr rvhich rlcclarstjon i* bcing nradrt4. FIat / Iloor I lllock No. ir. Name tf Prenrises 6. *Status7. :lssessed in which \Yard / Circle

8. Road I Street / Lane 9. Area / Locality 1.0. AO Code{under whomassessed last time)

Area AO Range AO11.. Town / CiLy / District 12. Siate

13. PIN1,1. Last Assessment Year in

lvhich assessed15. Ernail elcPtrurrtr 1?. Present Ward / Circle

1$. llesitlential Status {rvithin thcmeaning of Section 6 of the lncome.-TarAct,1961)19. Name of Business / Occupation

20. Present A0 Code (if not snme as above)21. Jurisdictional Chief Commissioner of lrrcome-tax or ('llommissioner of

Income-tax {if not assessed to Income-tax earlier}AreaCoda

AO RangeCode

AONo.

22. lstimated total income from the sour'(es mentioned below : (Piease tiek the relevant box)Dirriilend from shares rctbrred to in Sehedule I nInterest on semritie$ referled to in Schedule II n

Interest on Burn$ refered to in Schedule III nIncome form units referred io in $chedule tV

The amount of withdmw&l rcfrrrcd to in smtion 8fi:CAr2{a) finm Natirxul Savings Schenre referrcd tn in ScheduleY23. Dstimated iotal income of the prrrious year in whidr incon"re mentioned in Column 2t is to be included

94. fJetailg nf investments in respect of rvhich the declaration is being made :SCHIIDT.ILE . I

(Details of shares, which stand in the name of the declarant and treneficially orvnt:d by hirn)Date(s) iin \vhiclt'the shar:es wereDistinctive uuml:ers

of the shares0lass of ehaiea & f

value bf ebch sh*re

SCHEDULD . IIfletails gf the *eiurities held in the name of declarant and beneficially owned try him)

I)pscription ol'sccurities

Number ofsecuritics

Arr:ount ofscc nrities

SCHEDULE . III{Detail.s eif the sums given b.y the declarant on interest)

anre and addrss; of the pcrson t$the eums'are given on interest

SCHEDULE - IY

SCHEDULE - V(Detailg of the withdrawal mado from National IJa Sclreme)

--x--* \ Signature of lhe dcclarantDeclaration / Yerifrcation

declare that in the hest of *my 1 our knowledge and beliefwhat is stated above is correct, complete and is truly stated. *I / 1,[e declare thatthe incomes refemed to in this form are not includible in the total income of any other person u/e 60 to M of the Income-tsx Act, 1961.*I / We further, declare that the tar *on my / our estimated total income, including tincome r' incomes referred to in Column 22 above,computed in accordance rvith the provisions of the Income-tax Act, 1961, for tlre previous year ending on ...................relevant to trhe asaessment yar ....,.,..... will tre nil. *I / We also. declare thnt *my / our *ineome / incomesreferred to in Column 22 for the previous year ending on ............."..... .......... ...... relevant to the asses*mentyear ,....,.,.....,.. will aot exceed the maximum amount which is not chargeable to income-tax.

x' Signature of the declarant

Forwarded to the Chief Corxrnissioncr or Cournrissioner of Incoms-ttrx

Signature of'the pe.rson responsible for paying thein.catne referretl to in aolunm 22 of Part I

PA1BT.IIFor use the to whom the declaration is fuurished

l. Name of thr; person responsible for paying the ineome rel'errecl to in Column 22 of Part I 2. PAN of the pereon indicated in Column I of Part II

8. Complete Address 4. 'l'AN of the person indicated in ColumnI of Part II

5. Email 6. Telephone No. (wit"h $ID Code) and Mobile No. 7. Slatus

8. Date on which Declaration isFurnished (dd1mm/yyyy)

9. Period in regpeci ofwhieh the dividend has beendeclarrd or the inmme hos b..sn paid / creditsd

10. Amount ofincome paid

11. Date on which theincome hns been paid/eredited (dd/mrn/iyyy)

LZ. Dale ol declaratron. dlstribuuon or Davment of dividend iwithdrawal under the National Savingd S