15G Form Idbi Bank – Fill Out and Use This PDF

"FORM NO. 15G”

[See section 197A(1), 197A(1A) and rule 29C]

Declaration under section 197A(1) and section 197A(1A) of the Income‐tax Act, 1961 to be made by an individual or a person (not being a company or firm) claiming

certain receipts without deduction of tax.

PART I

1. Name of Assessee (Declarant)					2. PAN of the Assessee
					3. Assessment Year
					(for which declaration is being made)
4. Flat/Door/Block No.		5. Name of Premises			6. #Status
					7. Assessed in which Ward/Circle
8. Road/Street/Lane		9. Area/Locality			10. AO Code
					(under whom assessed last time)
11.	Town/City/District	12. State			Area Code	AO Type	Range Code	AO No.
			13. PIN
					14. Last Assessment Year in which assessed
15.	Email	16. Telephone No. (with STD Code)			17. Present Ward/Circle
		and Mobile No.
					18. Residential Status
					(within the meaning of Section 6 of the
19.	Name of Business/Occupation
					Income Tax Act,1961)
					20. Present AO Code (if not same as above)
21.	Jurisdictional Chief Commissioner of Income‐tax or Commissioner of Income‐tax				Area Code	AO Type	Range Code	AO No.
	(if not assessed to Income‐tax earlier)
22.	Estimated total income from the sources mentioned below:
							(Please tick the relevant box)
				Dividend from shares referred to in Schedule I
				Interest on securities referred to in Schedule II
					Interest on sums referred to in Schedule III
				Income form units referred to in Schedule IV
	The amount of withdrawal referred to in section 80CCA(2)(a) from National Savings Scheme referred to in ScheduleV
23.	Estimated total income of the previous year in which income mentioned in Column 22 is to be included
24.	Details of investments in respect of which the declaration is being made:

SCHEDULE‐I

(Details of shares, which stand in the name of the declarant and beneficially owned by him)

SCHEDULE‐II

(Details of the securities held in the name of declarant and beneficially owned by him)

SCHEDULE‐III

(Details of the sums given by the declarant on interest)

SCHEDULE‐IV

(Details of the mutual fund units held in the name of declarant and beneficially owned by him)

SCHEDULE‐V

(Details of the withdrawal made from National Savings Scheme)

Particulars of the Post Office where the account under the National Savings Scheme	Date on which the account	The amount of withdrawal
is maintained and the account number	was opened (dd/mm/yyyy)	from the account

**Signature of the Declarant

Declaration/Verification

*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 declare that 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‐tax Act, 1961. *I/We further, declare that the tax *on my/our estimated total income, including *income/incomes referred to in Column 22 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. *I/We also, declare that *my/our *income/incomes referred to in Column 22 for the previous year ending on________________relevant

to the assessment year_________________will not exceed the maximum amount which is not chargeable to income‐tax.

Place:___________________
Date:___________________
									Signature of the Declarant
				PART II
		[For use by the person to whom the declaration is furnished]
1.	Name of the person responsible for paying the income referred to in Column 22 of Part I					2. PAN of the person indicated in Column 1 of Part II
3.	Complete Address					4. TAN of the person indicated in Column 1 of Part II
5.	Email		6. Telephone No. (with STD Code)			7. Status
			and Mobile No.
8.	Date on which Declaration is Furnished		9. Period in respect of which the dividend			10. Amount of income paid			11. Date on which the income
	(dd/mm/yyyy)		has been declared or the income has been						has been paid/credited
			paid/credited						(dd/mm/yyyy)
12. Date of declaration, distribution or payment of dividend/withdrawal					13. Account Number of National Saving Scheme from which withdrawal
	under the National Savings Scheme (dd/mm/yyyy)				has been made
Forwarded to the Chief Commissioner or Commissioner of Income‐tax____________________________________________
Place:___________________
Date:___________________
							Signature of the person responsible for
							paying the income referred to in
								Column 22 of Part I

Notes:

1.The declaration should be furnished in duplicate.

2.*Delete whichever is not applicable.

3.#Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a firm) under section 197A(1A).

4.**Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.

5.Before signing 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 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 6 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 3 months but which may extend to two years and with fine.

6.The person responsible for paying the income referred to in column 22 of Part I shall not accept the declaration where the amount of income of the nature referred to in sub‐section (1) or sub‐section (1A) of section 197A 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 amount which is not chargeable.

IDBI Bank Limited, Regd. Office: IDBI Tower, WTC Complex, Cuffe Parade, Mumbai – 400 005.

Toll Free Numbers reachable from any landline/Mobile phones: 1800-200-1947 / 1800-22-1070, Non - Toll Free Number: 022-66937000. Website: www.idbi.com