2024 07 1 13 10 18 15GH - Acknowledge

FORM NO.
15G
[See section 197A(1), 197A(1A) and rule 29C]
Declaration under section 197A (1) and section 197A (1A) to be made by an individual or a person
(not being a company or firm) claiming certain incomes without deduction of tax.
PART I
1. Name of Assessee (Declarant) : KAJAL A SAMANI 2. PAN of the Assesee1 : BSDPS9708P
3. Status2 : Individual 4. Previous year(P.Y.)3(for which declaration is being made): 5. Residential Status4 : Resident
2023 - 2024
6. Flat/Door/Block No. : NEW 7. Name of Premises : MALAD 8. Road/Street/Lane : 9. Area/Locality :

GITANJALI CHS E-5,RAHEJA EAST,NR SAIBABA MANDIR
TOWNSHIP,
10. Town/City/District : MUMBAI 11. State : MAHARASHTRA 12. PIN : 400097 13. Email :
[email protected]
14. Telephone No. (with STD Code) and Mobile No. : 15 (a) Whether assessed to tax under the Income-tax Act, Yes No
9004901931
19615 :
(b) If yes, latest assessment year for which assessed: 2023-24
16. Estimated income for which this declaration is made : 290.00 17. Estimated total income of the P.Y. in which income mentioned in column
16 to be included6 : 290.00
Total No. of Form No. 15G filed Aggregate amount of income for which Form No.15G filed
1 290.00
Sl. Identification number of relevant Nature of income Section under which tax is deductible Amount of income
No. investment/account, etc.8
1 028110026618 Interest on deposits 194A 74
Form is generated through iMobile App.

Thus, signature of the customer is not required
...................................................
Signature of the Declarant9
Declaration/Verification10
*I/We, KAJAL A SAMANI do hereby declare that to the best of *my/our knowledge and belief what is stated above is correct, complete and is truly stated. *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. *I/We
further declare that the tax *on my/our estimated total income including *income/incomes referred to in column 16 *and aggregate amount of *income/incomes
referred to in column 18 computed in accordance with the provisions of the Income-tax Act, 1961, for the previous year ending on 31st March, 2024 relevant to the
assessment year 2024 - 2025 will be nil. *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 31st March, 2024 relevant to the assessment year 2024 - 2025 will not exceed the maximum amount which
is not chargeable to income-tax.
Place:....................
Date:07/01/2024 Form is generated through iMobile App.

Thus, signature of the customer is not required
....................................................
PART II
[To be filled by the person responsible for paying the income referred to in column 16 of Part I]
1. Name of the person responsible for paying : ICICI Bank Limited 2. Unique Identification No.11 :
3. PAN of the person 4. Complete Address : ICICI Bank Towers, Bandra-Kurla 5. TAN of the person responsible
responsible for paying : AAACI1195H Complex, Mumbai - 400 051 for paying :
6. Email : 7. Telephone No. (with STD Code) 8. Amount of income paid12 :

and Mobile No. :
9. Date on which Declaration is received 10. Date on which the income has been paid/credited
(DD/MM/YYYY) : 07/01/2024 (DD/MM/YYYY) :
Place:.....................
Date:......................... ..............................................................................
Signature of the person responsible for paying
the income referred to in Column 16 of Part I
*Delete whichever is not applicable.

1As 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).
2Declaration can be furnished by an individual under section 197A(1) and a person (other than a company or a firm) under section 197A(1A).
3The financial year to which the income pertains.
4Please mention the residential status as per the provisions of section 6 of the Income-tax Act, 1961.
5Please 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.
6Please mention the amount of estimated total income of the previous year for which the declaration is filed including 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. 15G filed along
with the aggregate amount of income for which said declaration(s) have been filed.
8Mention the distinctive number of shares, account number of term deposit, recurring deposit, National Savings Schemes, life insurance policy number, employee
code, etc.
9Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
10Before signing the declaration/verification, the declarant should satisfy himself that the information furnished in this form 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 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.
11The person responsible for paying the income referred to in column 16 of Part I shall allot a unique identification number to all the Form No. 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. In case the person has also received Form No.15H during the same quarter, please allot separate series of serial
number for Form No.15G and Form No.15H.
12The person responsible for paying the income referred to in column 16 of Part I shall not accept the declaration where the amount of income of the nature referred
to in sub-section (1) or sub-section (1A) of section 197A or the aggregate of the amounts of such income credited or paid or likely to be credited or paid during the
previous year in which such income is to be included exceeds the maximum amount which is not chargeable to tax. 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.;

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FORM NO.

6. Flat/Door/Block No. : NEW 7. Name of Premises : MALAD 8. Road/Street/Lane : 9. Area/Locality :

1 028110026618 Interest on deposits 194A 74

Form is generated through iMobile App.

Date:07/01/2024 Form is generated through iMobile App.

6. Email : 7. Telephone No. (with STD Code) 8. Amount of income paid12 :

*Delete whichever is not applicable.

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