Bar Code 464110000001 il a FORM NO. 15H [See section 197.A(1¢) and rule 29C] Declaration under section 197A(1C) to bemade by an individual whe is of the age of sixty years er more claiming certain incomes without deduction of tax. PARTI 7 Name of Accesses (Declarant) Z PAN of tie Assessse” | 3. Date of Bia (woimmrryyy) 4 Previous year(P Y)° Gor which declaration 1s being made] 3 Fav DoorBiock No @ Name of Premises T RoadiStredt/Lane | & ArealLocalty D TewaiCuyiDatet | 10 Stee TT Pi 12 Email 13 Telephone Wo (aith STD Code) and Mobile No 14 (a) Whether assessed to tas” Vest] (b) LEyer, latest assestment year for which asvecced No[_] 75. Estineied income Tor which ts dedarsion 1s made 16, Edimaled bial Income of he PY in which come mentioned in columa 15 to be sncluded? 17 Details of Form Na 13H ather than this form Sled fas the premons year, aay Teta No. of Form No.15H Bled ‘Aggrogate amount ofincome farwhich Fon No.15H filed 38 Details ofincome for which the declaration is Aled Sl | MdetiGcain — muanber of No. | relevant investment account, eto! Wane ofmonie Section onder which tax is deductiale Araoun oF moome HEFCE ANE LID ecusTD: @FDRD NO @FDRD NO FORD NO (FLARD NO @FDRD NO DFDRD NO @FDRD NO sven oan er Signature of the Declarant ‘Mandatory : Tobe filled by the Branch (Cheeldist for Form 15 H (For individual >~ 60 years} w have checked and contin the below Tick vor) fo ‘Ne uegwatend poured Customer is >— 601 years (if <60 yearsthen ill fra 15 6° BANNo isundabed in ani Records acainst the Cust id of custorner Copy of PAN Caratiached iProt mpdste in the ster) Costner has signedin sx plates ndicated yy 2 Fies marist are mardatry tobe led Name ofthe Emp Erp, Cote Emp. Siga DateDeclaration’ Verification® L do hereby declare that Tam resident in India within the meaning of section 6 of the TIncome-tax Act, 1961. T also hereby declare that to the best of my knowledge and belief what is stated above is comect, complete and is truly stated and 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 Incomestax Act, 1961. [further declare that the tx on my cstimated total income including *incomelincomes referred to in column 1S *and aggregate amount of *incomesincomes referred to in colutnm 17 computed in accordance withthe provisions of the Income-tax Act, 1961, for the previous year ending on relevant to the assessment year. -will beni wr Phace: Signature of the Declarant Date PARTIE [To he filled by the person responsible for paying the income referred to in column 15 of Part I] [Nene of the panian reaponible far paying © Unique Identification No. 3. PAN of the person Tesponsible Tor [4 Complete Address] 5. TAN of the pawson responsible for paying paying 6 Email 7, Telephone No. (with STD Code) and Mobile | 8 Amount of income paid” No. 9._Date an which Declaration is received | 10, Date on which the income has been paid/credited ODMMYYYY) @DMMYYYY) "Signature ofthe person responsible for paying Date the income referred to in column 15 of Part 1 Dales whichever ct apie ‘sper roms of cen 20680), the detec une ein (7TACIC) sll be i did ifthe dae a wld Ponce Acc Nabe (PAW. {Der can bs uisel by azeadent nde wins fthe age of yen or ore at ny ne ag the previous yar Sue Euaecalyea to uct acca pats ‘Hewesueion "Vor sfascsn! cat uss opronsensoflacwae ta Act 191 for ayy oe wisn ear ot os cseeaal yous pescing to You ia which he bela ie ed ‘Bisse neonon he annie ofsinad real come ofthe grevous parr ah the desLarsin (sled etig the anew fincas or eih as declan setae ‘tn cay dcinabont)n Frm No STs bled befre Hingas decarion donagthe ronous ye, mein he tld nner of sch Fonn Ne. 15H Ged ong wih he sepere aunt efincoe for hick sat derions)haveher ed, ‘Mean the detate nuke of hares, enous mer finan dapat securing deposit, Neon Senage Subs ib snsirane ply ube, enlayes onde, te ‘afr ning the ert vain te delet hd ay inf hn she in ths i cree ed agin specs Ay pr laa se eatnentin te earn stl shes paseosben uote secton 27 of he ovomea At, 161 ard cp consieion te poate (Qaae tewhee ta sou tobeevalel acess nay Stel gees, wubegeospuscame whch shaloatVelesstn ae otsbom la chnay cea sesca yeas aden bor, {io anp ei ena th igre panes hich dl nee en Sm hes ate hi which may mn ao poe an eth ie STueperten ropenable Bepyig Witecome forest cana 1s fPat Ish lt sung ders eaten anberts the orm Ne ISH received by him dig aguater fe Sarl yes repartee umber eng wth he pate peel nae 3 (8) ofthe pont Fale, 19628 fe TDS rede uae the Sanz quate casei poson has dlufceved fom No 10 dag the sue quae, les lt Spare sms of end wih Ex Fos No 1 aud Fons e150 tog quot espnahle Ogata te acomesfered wp colin 1 of Pall at snap the deren hese he nou ofiacene of hose fotare tia een IB TA(LG oe he sagegse ofa ents ach income eee psd ce Mey tb ede orga dana oe reins yer in Ruch sch came sts bose exeede ‘he tacn aot which eat cares tac ate mag fn ebton() under Cages Vln fay wt ffeSlos any, wth ead “nce Hon ose ope? Lrwieh te dear ee Fer ea the sist, e's reyued te en Soeume or ie agrepde smut finer ethe rember by he ecamtin eum 1 an 17"46110000001 Bar Code i FORM NO. 15H it Declaration under section 197A(1C) to bemade by an individual whe is of the age of sixty years er more claiming certain incomes without deduction of tax. PARTI T Nae of Aesessoe (Declarant) PAN ofthe Assessee" | 3. Date of Bint wpmmryyy) 4 Frevious year(P ¥)° Gor which 5. FlavD oosBlock No 6 Name of Premises declaretion is being made T RoadiSueet/Lane | & AvealLocality 9. TownlCuyfbetct | 10, Stare iT EW 12 Bevall Ta Telephone Wo (uith STD Code) and Mobile Na TA @) Whether assessed to tx” Vest] Nel] () [Eyes, latest assessaent yeor fos which accessed Ts Estimaied income for which ths declaraion is] 16. Eaimeted total Income of tae PY in waich icone sade meaticnedin caluma 15 te be sncluded? 17 Details of Form Na 19H ather than this forma Sled fs the premons year, aay Totd No, of Form No.15H Blea ‘Aggrogate amount ofincome farwhich Fon No.15H filed 18 Details ofincome for which the declaration is Aled Sl) MewtiGicaion — muinber of | Naure of monme Section onder which | Amount ofimcume Ne, | relevant investmert! account taxis deductible eto HEFCE ANE LID @cusT D: @FDRD NO. @FDRD NO @FDRD NO (FLRD NO @FDRD NO DFDRD NO @FDRD NO Signature of tae Declerant is unter ye Sd sven goonsDeclaration’ Verification® L do hereby declare that Tam resident in India within the meaning of section 6 of the Tncome-tax Act, 1961. I also hereby declare that to the best of my knowledge and belief what is stated above is correct, complete and is truly stated and 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 Incomestax Act, 1961. | further declare that the tc on my cstimated total income including *incomelincomes referred to in column 1S *and ageregate amount of *incomesincomes referred to in colunnm 17 computed in accordance withthe provisions of the Income-tax Act, 1961, for the previous year ending on relevant to the assessment year. will benil r Place: Signature of the Declarant Date: PART IT [To be filled by the person responsible for paying the income referred to in column 18 of Part I) T. Name of the person responsible for paying © Unique Identification No. 3. PAN of the person responsible for] 4. complete Address] 5. TAN of the peson responsible for paying paying 6 Email 7, Telephone No. (with STD Code) and Mobile | 8. Amount of mcorne paid" No. 9._Date an which Declaration is received | 10, Date on which the income has been paid/credited @DMMYYYY) @DIMMYYYY) " Signature ofthe person responsible for paying Date the income referred to in column 15 of Part 1 Dabs whichever ct pile ‘spor romstes of cen 20680), the detec une ein {9TACIC) sal be did ifthe dae a wld Pemacete Acca Nabe (PAW. 2D can be urssel by areadent nad wine fthe age oF 0 yom or mare at any ne ag the previous year "ue Fuaecalyea to uct acon pats ‘Howestetion "Yor fascia cat uss Uo pronsens of lacnae ta Act 191 for ayy of he wets ear oto. csetact yous pescing the Youn hic the etnies ‘Bisse necnon te annie ofsinad real scome fb revue arf ach the desLarsin (sled etg the anew fiacose reich as delaaon sara ‘tna ny decinabe()n Frm No SH bled efre Hingis decarain dunagthe enous ye, mon he tld nab of sch Fonn Na. 15H Ged lang wh fhe seperes sont fincas for vhich sat dnerions)haveher ed ‘Meaicathe dette sucker of hares ena maser fem fio at scurig dept Neon Senage Subs ibinsirace ply ube, enlayes onde te ee cee aR eek aa irl ie ren eect cele le epee pula 2 se eatneatin te detarten shales pasesten uote secton 17 ofthe lovomear At, 161 sto conoion te poate (Qaue tower tar oud toleevalel ceeds nay Stel rupees, wubegwospuscae whch salon Velesstan as aotisbo la chnay cea sevca yeas adit bo, {Go anp ei en th ire ponies hich dl nee ev Sm hes ah which may med an poe noth ie "Theperten ropanable Bepyig totes forest icant 1s Pat Ish lst sung ders eaton rnberts ol the orm Ne ISH received by him ding aguater fhe nan years repartee urbe eng wth he pate peel nae 3.8) oft ponte Fale, 1962n fe TDS cetera ashe the Sau uate i casei poson hs alu sccved oma No 0 daoathe se quae, les lt spare sms of end wih Ei Poa No 1 aad Fons e150 hog cuetsespenahle gata te acome fered wp colin 1 of Patil at scape deren ee he noun finan of hase floret ia een IB TA(LG oe he sagepse ofa nents fac income eee psd ce My to be eed orga dana oe reins yer in Ruch sch ora ists bose exeede ‘he tacan aor which et cares sta ate mag fo eton() wader Chae Vio fp ew feos any, we th ead “nce Boo ose ope? Grwich te dears Fer dea the sally, bes raped te en Socmeo ie agrepde smut fincas ethe crema b repre he ecacntin elem an 17" Disclaimer 1. Form 15H isto be filled only or Incivi als more than or equal to 60 years (I< 60 yrs then fll Form 150) 2. TDS waiver will not be marked if PAN details ore not updated on the Bank's records 3. TDS waiver will be marked from the de of submission ofthis form 4. "TDS which has already been desiucted will not be refunded back and to be sought-from Income Tis department. 5. fresh Fonm 15H needs to be submaitied in each new Financial Year within the start of the Financial Year. 6. orm 1SH needs tobe submitted in Thiplicate 1. Form 1S Hneeds to be submitted tor every fixed deposit booked with the Bank. 8. The Bank shall not be lable for any consequences or los aising due to delay or non or wrong submission of Form 15H 9. UWe fully understand that wrong quoting of PAN may result in penal consequences under section 2725 of lacome Tas act 1961 and the bank is not responsible for my consequences arising die wrong quoting of PAN464110000001 Bar Code a FORM NO. 15H i Declaration under section 197A(1C) to bemade by an individual whe is of the age of sixty years er more claiming certain incomes without deduction of tax. PARTI 7 Name of Accesses (Declarant) PAN ofthe Assessse” ) 3, Date of Bint (woimmrryyy) 4 Previous year(P V)° Gor which 5 FlevDoorBlock Ne @ Name of Premises doclarction is being mado T RoadiStredt/Lane | & ArealLocalty D TewaiCuyiDatet | 10 Stee TT Pi 12 Email 13 Telephone Wo (aith STD Code) and Mobile No 14 (a) Whether assessed to tas” Vest] Nal] (b) LEyer, latest assestment year for which asvecced 75. Estineied income Tor which Ws dedarsion 1s] 16. Sdunced lal income of he PY in which come made mentioned in columa 15 to be sncluded? 17 Details of Form Na 13H ather than this form Sled fas the premons year, aay Teta No. of Form No.15H Bled ‘Aggrogate amount ofincome farwhich Fon No.15H filed 18) Details of income for which the declaration is Bled Sl | IdentiGcetion —tumnber of | Nature of moome Seaton under which | Amount ofmoome Ne. [relevant investinert! account taxis deductiale ete HOFCBANK LID OCusT D: @FDRD NO @FDRD NO FORD NO FORD NO @FDRD NO FORD NO @FDRD NO Signature ofthe Declerant sven oanDeclaration’ Verification® L do hereby declare that Tam resident in India within the meaning of section 6 of the Tncome-tax Act, 1961. T also hereby declare that to the best of my knowledge and belief what is stated above is correct, complete and is truly stated and 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. [further declare that the tc on my cstimated total income including *incomelincomes referred to in column 1S *and aggregate amount of *income/incomes referred to in colutnm 17 computed in accordance withthe provisions of the Income-tax Act, 1961, for the previous year ending on relevant to the assessment year. -will beni wr Phace: Signature of the Declarant Date PARTIE [To he filled by the person responsible for paying the income referred to in column 15 of Part I] TSG IE pene reg TSU Toe © Unique Identification No. 3. PAN of the person responsible Tor [4 Complete Address] 5. TAN of the peson responsible for paying paying © Email 7, Telephone No. (with STD Code) and Mobile | 8 Amouit of income paid” No. 9._Date an which Declaration is received | 10, Date on which the income has been paid/credited ODMMYYYY) @DMMYYYY) "’Signature ofthe person responsible for paying Date the income referred to in column 15 of Part 1 Dales whichever not apie ‘sper promstes of cen 20680), the detec une ein 19TACIC) sll bs dd ft dare a wld Ponca Acct Naber (PAW. {Der can be umssel by areadent nad wins ofthe age of 0 yen or ore at ay ne dag the revo yar "ue Euaecalyea to wluchthe acon pats ‘Heweseeion "Vor sfazcsa far uss to pronsen of lacwas ts Act 191 for any of he cio ear ot os eset Yous pescing ts Youn hic the belated ‘Bisse econ te anoint of sinad real scome ofthe revive yar for ach the desLarsin (sled tg the anew fiacos reich as declan setae ‘tnca ny declan) in Frm No. SH bled efre Hing is decarien donagthe enous yew, mon etd nunber of sch Form Ne. 15H Ged lang wih he seperee sont efincoe for vhich eat dnerions)haveher ed ‘Meaicathe detate nuke of hares, enous mer fam fips scurg dept, Neon Sunage Subs ibsnsirace ply ube, layne, te Feet elle teeta Lec Atel Te Geert ge et leg lege lege laa 2 se eatneatin te earn shale ihe paseosten uote secton 27 ofthe ovomea At, 161 ard conaieionte poate (Gane tewhee ta sought ole evalel acess rnd Stel ugees, wubeguosspuscae whch salon Uelesstn ae uotsba la chnay cea sesea yeas adh bo, {io anp ei na th igre inpamnnt mich dl nee Sm hes ate hi which may ned an pet an eth ie "Theperten repenable Spying Witesume forest cain 1s fPat Ish lt sung ders eaten rane the orm Ne ISH recrved by hi dig aguater fhe Sarl years repartee ume eng wth he pata ese nae 3 8) ofthe ponte Fale, 1920 fe TDS rede ashe the aur quate casei pon hase fescved fom Ne 10 date sue quae, les lt Spare sms end wiht Ex Poa No 1 aad Fons Ne 150 Dthogcuensespenahle Ogata te acome fered wp colin 1 of Pall at ana he deren eee nou ofan of hose flare tia een LB TA(LG) oe he sagegse ofa ents fac income eee psd ce Mey tb edge or ga dana oe reins yer in Ruch sch eco ists bose exeede ‘he tacn ao which eat cares tac ate ama fn dekon() wader Chater Vln, fay owt felony, we th eal “nce Hom hone ope? Lrwich te dedarat ele Fer ea the sgh, bes requ te eal oeume or he agrepde rau finer -ethe crema be reed by he Secaramtin ecu an 17" Disclaimer 1, Form 15H isto be filled only or Indivi als more than or equal to 60 years (i£< 60 yrs then fll Form 150) 2. TDS waiver will not be marked if PAN delails are not updated on the Bank's records 3, TDS waiver will be marked from the date of submission ofthis form 4. "TDS which has already been deshucted will not be refund back andto be sought-from Income Tis department. 5. Afresh Form 15H needs o be submaitied in each new Financial Year within the start of the Financial Year 6. orm 1SH needs tobe submitted in Thiplicate 7. Form LS H needs to be submitted for every fixed deposit booked with the Bank. 8. The Bank shall not be lable for any consequences or loss aising due to delay or non or wrong submission of Form 15H 9. UWe fully understand that wrong quoting of PAN may result in penal consequences under section 2725 of lacome’Tax act 1961 and the bank is not responsible for my conse quences arising die wrong quoting of PAN