Form No. 15 H: Bar Code: Pan
Form No. 15 H: Bar Code: Pan
Form No. 15 H: Bar Code: Pan
FORM No. 15 H
[See section 197A(1C) and rule 29C(1A)]
Declaration under section 197A(1C) of the Income-tax Act, 1961 to be made by an individual an individual who is of the age of
sixty years or more claiming certain receipts without deduction of tax
PART-I
1. Name of Assessee (Declarant) 2. PAN of the Assessee
15. Email 16. Telephone No. (with STD Code) and Mobile No. 17. Present Ward/Circle
18. Name of Bussiness/Occupation 19. Present AO Code (if not same as above)
20. Jurisdictional Chief Commissioner of Income-tax or Commissioner of Income-tax ( if not assessed to Area Code AO Type Range Code AO No.
Income-tax earlier)
The amount of withdrawal referred to in clause (a) of sub-section 2 of section 80CCA referred to in Schedule V
22. Estimated total income of the previous year in which income mentioned in Column 21 is to be included
SCHEDULE III
Name and Address of the person to whom the sums are given on interest Amount of sums given on Date on which sums were given Period for which such Rate of interest
interest on interest sums were given on
(DD/MM/YY) interest
FD NO :
FD NO :
FD NO :
FD NO :
FD NO :
FD NO :
FD NO :
FD NO :
FD NO :
Signature of declarant
Declaration / Verification
I ................................................. do hereby declare that I am resident of India within the meaning of section 6 of the Income-tax Act, 1961. I also, hereby declare
that to the best of my knowledge 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 u/s 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 21 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.
Place: ..................................................
Date: ..................................................
.............................................................................
Signature of Declarant
PART II
[For use by the person to whom the declaration is furnished]
1. Name of the peron 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
HDFC BANK LTD
3. Complete Address AAACH2702H
HDFC Bank House, Senapati Bapat Marg, Lower Parel, Mumbai, Maharashtra - 400013 4. TAN of the person indicated in Column 1 of Part II
5. Email : support@hdfcbank.com 6. Telephone No. (with STD code) and MUMH03189E
Mobile No. 7. Status Domestic Company
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
has been declared or the income has been income has been
(dd/mm/yyyy) paid/credited paid/credited
(dd/mm/yyyyy)
12. Date of declaration, distribution or payment of dividend/withdrawal under the National 13. Account number of National Saving Scheme from
Savings Scheme (dd/mm/yyyyy) Not Applicable which withdrawal has been made Not Applicable
Notes:
1. @ Give complete postal address.
2. The declaration should be furnished in triplicate.
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
conviction be punishable -
(i) In a case where tax sought to be evaded exceeds twnety-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;
5. The person responsible for paying the income referred to in column 21 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 amount which is not chargeable to tax and deduction(s) under Chapter
VI-A, if any, for which the declarant is eligible.";
Disclaimer
1. Form 15H is to be filled only for Individuals more than or equal to 60 years ( if < 60 yrs then fill Form 15G)
2. TDS waiver will not be marked if PAN details are not updated on the Bank's records
3. TDS waiver will be marked from the date of submission of this form
4. TDS which has already been deducted will not be refunded back and to be sought from Income Tax department
5. A fresh Form 15H needs to be submitted in each new Financial Year within the start of the Financial Year.
6. Form 15H needs to be submitted in Triplicate
7. Form 15H needs to be submitted for every fixed deposit booked with the Bank.
8. The Bank shall not be liable for any consequences or loss arising due to delay or non or wrong submission of Form 15H
9. I/We fully understand that wrong quoting of PAN may result in penal consequences under section 272B of Income Tax act 1961 and the bank is not
responsible for any consequences arising due wrong quoting of PAN