Form 15g - Declaration Under Section 197a(1) And Section 197a(1a) Page 3

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SCHEDULE IV
Name and address
Number of
Class of units
Distinctive
Income in
of the Mutual Fund
units
and face value
number of units
respect of units
of each unit
SCHEDULE V
Particulars of the Post Office
Date on which the
The amount of withdrawal
where the account under the
account was opened
from the account
National Savings Scheme is
maintained and the account
number
________________________.
**Signature of the declarant
Verification
*I / We ______________ do hereby declare that to the best of *my / our knowledge and belief what
is stated above is correct, complete and is truly stated.
Verified today, the day__________ day of ________
Place______________
____________
Signature of the declarant
Note:
1. @ Give complete postal address.
2. The declaration should be furnished in duplicate.
3. *Delete whichever is not applicable.
4. # Declaration in respect of these payments can be furnished by a person (not being a company or a firm).
5. **Indicate the capacity in which the declaration is furnished on behalf of a Hindu undivided family
6. 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.

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