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FORM NO.15H – (AGE MORE THAN 60 YEARS)
Declaration under section 197A(1C) to be made by an individual who is of the age of sixty years or more claiming certain incomes without deduction of tax.
1. Name of Assessee (Declarant): * 2. Permanent Account Number of the Assessee * 3. Date of Birth *
4. Previous year (P.Y.) (for which declaration is being made) 5. Flat/Door/Block No. 6. Name of Premises
7. Road/Street/Lane 8. Area/Locality 9. Town/City/District 10. State
11. PIN 12. Email * 13. Telephone No. (with STD Code) Mobile No. *
14 (a) Whether assessed to tax:
(b) If yes, latest assessment year for which assessed
15. Estimated income for which this declaration is made
16. Estimated total income of the P.Y. in which income mentioned in column 15 to be included
17. Details of Form No.15H other than this form filed for the previous year, if any
Total No. of Form No.15H filed Aggregate amount of income for which Form No.15H filed
18. Details of income for which the declaration is filed
Sl.No Identification number for relevant Investment/account, etc. Nature of income Section under which tax is deductible Amount of income
1

Declaration / Verification

I do hereby declare that I am resident in 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 under sections 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 15 *and aggregate amount of *income/incomes referred to in column 17 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.



User's Signature