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FORM NO
...
PART I
1
...
PAN of the Assessee1
3
...
Flat/Door/Block No
...
Previous year(P
...
)3
5
...
Name of Premises
8
...
Area/Locality
10
...
State
12
...
14
...
(with STD
Code) and Mobile No
...
Estimated income for which this declaration is made
17
...
Y
...
Details of Form No
...
of Form No
...
15G filed
19
...
Identification number of relevant Nature of income
No
...
8
Section under which tax
is deductible
Amount of income
………………………………………
...
*I/We declare 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
...
relevant to the assessment year
...
*I/We also declare that *my/our *income/incomes referred to in column 16 *and the aggregate amount of
*income/incomes referred to in column 18 for the previous year ending on
...
will not exceed the maximum amount which is not chargeable to income-tax
...
Date: ………………………………………………
...
Signature of the Declarant9
PART II
[To be filled by the person responsible for paying the income referred to in column 16 of Part I]
1
...
Unique Identification No
...
PAN of the person
responsible for paying
4
...
TAN of the person responsible for paying
6
...
Telephone No
...
9
...
Date: ………………………………………………
...
Amount of income paid12
10
...
1
As per provisions of section 206AA(2), the declaration under section 197A(1) or 197A(1A) shall be invalid if the
declarant fails to furnish his valid Permanent Account Number (PAN)
...
3
The financial year to which the income pertains
...
5
Please mention “Yes” if assessed to tax under the provisions of Income-tax Act, 1961 for any of the assessment
year out of six assessment years preceding the year in which the declaration is filed
...
7
In case any declaration(s) in Form No
...
15G filed along with the aggregate amount of income for which said
declaration(s) have been filed
...
9
Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc
...
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 twenty-five lakh rupees, with rigorous imprisonment
which shall not be less than six 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 three months but which may
extend to two years and with fine
...
15G received by him during a quarter of the financial year and report this reference
number along with the particulars prescribed in rule 31A(4)(vii) of the Income-tax Rules, 1962 in the TDS statement
furnished for the same quarter
...
15H during the same quarter, please
allot separate series of serial number for Form No
...
15H
...
For deciding the
eligibility, he is required to verify income or the aggregate amount of incomes, as the case may be, reported by the
declarant in columns 16 and 18