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.

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....9. Town/City/District 10. State         11. PIN 12. Email 13. Telephone No. (with STD Code) and Mobile No.       14 (a) Whether assessed to tax4: Yes   No   (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 included5     17. Details of Form No.15H other than this form filed for the previous year, if any6 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 of relevant i....

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....e for paying the income referred to in column 15 of Part I] 1. Name of the person responsible for paying 2. Unique Identification No.9     3. 2[Permanent Account Number or Aadhaar Number of the person responsible for paying] 4. Complete Address 5. TAN of the person responsible for paying       6. Email 7. Telephone No. (with STD Code) and Mobile No. 8. Amount of income paid10       9. Date on which Declaration is received (DD/MM/YYYY) 10. Date on which the income has been paid/credited (DD/MM/YYYY)             Place: ....................................... Date: ....................................... ............................................

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....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 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. 9. The person responsible for paying the income referred to in column 15 of Part I shall allot a unique identification number to all the Form No. 15H received by him during a quarter of the financial year ....