FORM NO. 15H
[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 who is of the age of sixty years or more claiming certain receipts without deduction of tax.
PART - I
1] Name of Assessee (Declareant) : 2] PAN :
  3] Age: 4] Assessment Year 2013-14

5] Flat / Door / Block No. : 6] Name of Premises : 7] Assessed in which Ward / Circle
 
8] Road / Street / Lane : 9] Area / Locality : 10] AO Code (under whom assessed last time) :
  Area Code AO Type Range Code AO No.
11] Town / City / District : 12] State :
  14] Last Assessment Year in which assessed : 2012-13
13] PIN
15] Email : 16] Telephone / Mobile No : 17] Present Ward / Circle
 
18] Name of Business / Occupation : 19] Present AO Code (if not same as above):
 
20] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax (if not assessed to income tax earlier): Area Code AO Type Range Code AO No.

21] 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 from units referred to in Schedule - IV
 The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V
22] Estimated total income of the previous year in income mentioned in Col - 22 to be included :

23] Details of investments in respect of which the declaration is being made :