PART II

|To befilled by the person responsible for paying theincome referred to in column 16 of Part I

1. Name of the personresponsible for paying 2. Unique ldentification No. !!

Laxmam yiha sHCNOG lo0oh225 72
3. PAN of the person 4. Complete Address 5. TANof the person responsible for paying
responsible for paying
Bhole Baley Shele
6. Email 7. Telephone No. (with STD Codeahd Mobile No. 8. Amount of income paid!2

|ShindeDate4e@goalor
9.
sHEILS38is
which Declaration 10. Iþate on which the income has been paid/credited
received (DDMMYYYY)
(DDMMYYYY)

Place:
Sighature of the person responsible for paying
Date:.....
08o6|2023 the ncome referred to in column 16 of Part I

197A(1)
*Delete whichever is not applicable. iAs per provisions of section 206AA(2), the declaration under section
or 197A(1A) shall be invalid if the declarant fails to furnish his vhlld Perman ent Account Number (PAN).
Declaration can be furnished by an individual under sVction 197A() and a person (other
than acompany or afirm) under section l97A(1A).
The financial year to which the income pertains.
Plcase mention he residential status as per the provision of section 6 of the Income-tax Act,
1961.
Please mention *Yes" ifassessed to tax under the provisions of ncome-tax Act, 1961 for any of the assessment year
out of six assessment years preceding theyear in which the decla ation is filed.
6
filed including
Please mention the amount of estimated total income of the preous year for which the declaration is
the amount of income for which this declaration is made.
7In case any declaration(s) in Form No. 15G is filed before filing this declaration during the previous year,
mention
the total number of such Form No. I5G filed along with the aggregate amount of income for which said declaration(s)
have been filed. s Mention the distinctive number of shares, accourt number of term deposit, recurring deposit, National
Savings Schemes, life insurance policy number, employee code, qt.
Indicate the capacity in which the declaration is furnisled on behalf of a HUF.
AOP, ctc.
Before signing the declaration/verification, the declarart |should satisfy himself
that the information furnished in this form is true, correct and complkte in all respects. Any
under
pe:son making a false statement in the declaration shall be lial}le to prosecution
section 277 of the Income-tax Act, 1961 and on conviction be puishable
imprisonment
(i ina case where tax sought to be evaded exceeds wenty-five lakh rupees, with rigorous fine;
which shall not be less than six months but which may e7tend to seven years and with
less than three months but which
(ii) in any other case, with rigorous imprisonment rhich shall not be
may extend to two years and with fine. 11 The person resonsible for paying the income referred to in column
16 of Part Ishall allot a unique identification number to all the Form No. 15G received by him during a quarter
this reference number alopg with the particulars prescribed in rule 31A(4)(vii)
of the financial ycar and report
of the Income-tax Rules, 1962 in the TDS statement furhi_hed for the same quarter. In case the person has
fc Form
also received Form No.15H during the same quarter, plkase allot separate series of serial number
No.15G and Form No.15H.
declaration where
2Theperson responsible for paying the income referred to in colurhn l6 of Part Ishall not accept the
Runt ofincome of thenature refered to in sub-section (1) sub-section (1A) of section 197A or the aggregate
of the amounts of such income credited or paid or likely to be creqited or paid during the previous year in which such
incone is to be included exceeds the maximum amount which is rot chargeable to tax. For deciding the eligibility, he
le reguired to verity incOme or the aggr©gate amount of income. as the case may be, reported by the declarant in
columns 16 and 18.:
 "FORM NO.15G
[See section 197A(1). 197AlA)and rule 29C)

Declaration under section 197A () and section l97A(1A) tq be made by an individual or a person (not being a
company or firm) claiming certain incomes withoutdeduction of tax.
PART I
1. Name of Assessee (Declarant) 2. PAN of the Assessee!
3. Status Laxma VitthelSnNE (SyPsH
wdividucl
4. Previous year(P.Y.)'
2o09-201 4
(for which declaration is be<ng made)
5. Residential Status*
Resident
6. FlavD0or/Block No. 7. Na me of Premisesdha 8. Road/Street/Lane 9. Area/Locality
0
Iéerrja oon No-10sei
10. Town/City iistrict 11.Stadarshan
te colawy 12. PIN shelu 13. Email
Karsut
14.Telephone No. (with STD
maharashtsa
15 (a) Whether assessed to ax under the
Ishinteqmil- (om
Yes No
Code) and Mobile No. Income-tax Act, 196:
9Sq48|6S38 (b) 1fyes, latest assessment year for which
assessed
16. Estimated income for which this declaration is made 17. Estimated total income of the P.Y. in which
income mentioned in column 16 to be includedo

18. Details of Form No. l5G other than this form filed during the previous year, if any
Total No. of Form No. 15G filed Aggregae amount of income for which Form No. i5G filed

19. Details of income for which the declaration is filed

SI. Identification number of relevant Nature of income Section under which tax is Amount of income
No. investmen/account, etc. deductible

Signature of the Declarant

Declaration/Veriffcation
*/We LaXman SMINDE. do hereby declare that to th best of "my/our knowledge and belief what is stated
not includible
above is correct. complete and is truly stated. *I/We declare that<the incomes referred to in this form are
Act, 1961. *I/We further declare that
in the total income of any other person under sections 60 to 64 of the Income-tax
aggregate amount
the tax *on my/our estimated total income including *income/inomes referred to in column l6 *and
Income-tax Act, 1961,
of *income/incomes referred to in column 18 computedin accordahce with the provisions of the
for the previous year ending on 31J3|.2. relevant to the assessment year .0).Aillbe
nil. *I/Wealso declare
*income/incomes referred to in
that *my/our *income/incomes referred to in column 16 *and thÇ aggregate amount of
exceed the
column 18 for the previous year ending on 31.)3.A.relevantta the assessment year .D.0.ASvill not
maximum amount which is not chargeable to income-tax.

MUmBAT
Place:
Signature of the Declarant
Date:
Oslo6/2023