FORM NO. 15F
[See rule 29C(1)]
Declaration under section 197A(1) of the Income-tax Act, 1961, to be made by an individual claiming receipt of ‘Interest on securities’ without deduction of tax

I, 
son/daughter/wife of 
resident of 									do hereby declare

1.	that the securities, particulars of which are given below, stand in my name and are beneficially owned by me and the interest therefrom is not includible in the total income of nay other person under sections 60 to 64 of the Income-tax Act, 1961

Description of securities	No. of securities	Date(s) of
securities	Amounts of securities	Date(s) on which
the securities
were acquired by
the declarant	

					

2.	that my present occupation is : -
3.	that the tax on my estimated total income including the interest on securities referred to paragraph I above, computed in accordance with the provisions of the Income-tax Act, 1961, for the previous year ending on ------------------- relevant to the assessment year 19 -------- 19-------- will be nil.
4.	that I have not been assessed to Income-tax at any time in the past, but I fall within the jurisdiction of the Chief Commissioner or Commissioner of Income-tax ------------------------
OR
I was last assessed to Income-tax for the assessment year 19 -------- 19 -------  by Assessing Officer Circle/Ward/District --------------------------------- and the permanent account number allotted to me is ---------------------------
5.	that I am resident in India within the meaning of section 6 of the Income-tax Act, 1961.

Signature of declarant
Verification

I, ------------------------------------------------------------------------------------------- do hereby declare that to the best of my knowledge and belief what is stated above is correct, complete and is truly stated.
Verified today, the --------------------- day of ----------------- 19 -------------

Notes :
1.	@ Give complete postal address.

2.	The declaration should be furnished in duplicate.

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 one 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 three years and with fine

(FOR USE BY THE PERSON TO WHOM THE DECLARATION IS FURNISHED)

1.	Name and address of the person responsible for paying
‘interest on securities’ mentioned in paragraph I of
the declaration.

2.	Date on which the declaration was furnished by the
declarant

3.	Period for which interest is paid

4.	Amount of interest

5.	Date on which interest is paid.

Forward to the Chief Commissioner or Commissioner of Income-tax

Place -----------------------

Date ----------------------- 	------------------------------------------
		Signature of the person responsible for paying the ‘interest on securities’