Version No. 4.

0 – 17th April 2013 (NOC Copy)

FORM 15 (G)
See Section 197A(1), Section 197A(1A) and Rule 29(C)

Declaration under Section 197A(1) and Section 197A(1A) of the Income-tax Act, 1961,
to be made by an individual or a person (not being a company or a firm) claiming certain receipts without deduction of tax

Customer ID

PART I

1. Name of Assessee (Declarant) 2. PAN of the Assessee

3. Assessment Year
(for which declaration is being made)
4. Flat / Door / Block No. 5. Name of Premises 6. Status
7. Assessed in which Ward / Circle
8. Road / Street / Lane 9. Area / Locality 10. AO Code (under whom assessed last time)

Area Code AO Type Range Code AO no.

11. Town / City / District 12. State
13. PIN 14. Last Assessment Year in which assessed

15. Email 16. Telephone No. (with STD code) and 17. Present Ward / Circle
Mobile No. 18. Residential status (within the meaning of Section 6 of
Income Tax Act 1961)
19. Name of Business / Occupation
20. Present AO Code (if not the same as above)

21. Jurisdictional Chief Commissioner of Income Tax or Commissioner of Income Area Code AO Type Range Code AO no.
Tax (if not assessed to Income Tax earlier)
22. Estimated total income from the sources mentioned below:
(Please tick the relevant box)
Dividend from shares referred to in Schedule I

Interest on securities referred to in Schedule II

Interest on sums referred to in Schedule III

Interest from units referred to in Schedule IV

The amount of withdrawal referred to in Section 80CCA(2)(a) from National Savings Scheme referred to in Schedule V

23. Estimated total income from the previous year in which income mentioned in Column 22 is to be included

24. Details of investment in respect of which the declaration is being made:

Schedule I (Details of shares which stand in the name of the declarant and beneficially owned by him)
Number of Shares Class of shares and face Total face value of Distinctive numbers Date(s) on which the shares were acquired by the
value of each share shares of the shares declarant (dd/mm/yyyy)

Schedule II (Details of securities which stand in the name of the declarant and beneficially owned by him)
Description of Number of securities Date(s) of securities Amount of securities Date(s) on which the securities were acquired by
securities (dd/mm/yyyy) the declarant (dd/mm/yyyy)

Schedule III (Details of the sums given by the declarant on interest)

Name and Address of the person to Amount of such sums Date on which sums were given Period for which such sums Rate of Interest
whom the sums are given on interest given on interest on interest (dd/mm/yyyy) were given on interest

Schedule IV (Details of mutual fund units which stand in the name of the declarant and beneficially owned by him)
Name and Address of the Number of units Class of units and face Distinctive number of units Income in respect of units
Mutual Fund value of each unit

Schedule V (Details of the withdrawal made from National Savings Scheme)

Particulars of the post office where the account Date on which the account was opened The amount of withdrawal from the account
under the National Savings Scheme is (dd/mm/yyyy)
maintained and the account number

_____________________________⊗
Signature of Declarant
 (NOC Copy)

Declaration / 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. *I/We declare that the incomes referred to in this form are not includible in the total income of any other person under section 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 22 above, computed in
accordance with the provisions of the Income Tax Act 1961, for the previous year ending on …………………..relevant to the assessment year …………………….will be nil.
*I/We also declare that *my/our *income/incomes referred to in Column 22 for the previous year ending on …………………..relevant to the assessment year
…………………….will not exceed the maximum amount which is not chargeable to Income Tax.

Place: ………………………………….. _____________________________⊗

Date: …………………………………… Signature of Declarant

PART II [For use by the person to whom the declaration is furnished]

1. Name of the person responsible for paying the income referred to in Column 22 2. PAN of the person indicated in Column 1 of Part II
of Part I YES BANK LTD. AAACY2068D
3. Complete Address YES BANK LTD., Nehru Centre, 9th floor, Discovery of
India, Dr. A. B. Road, Worli, Mumbai - 400018 4. TAN of the person indicated in Column 1 of Part II
5. Email 6. Telephone No. (with STD Code) and MUMY02084F
Mobile No. (22) 66699000 7. Status Domestic Company
8. Date on which Declaration is 9. Period in respect of which the 10. Amount of income paid 11. Date on which income has been
furnished (dd/mm/yyyy) dividend has been declared or the paid/credited (dd/mm/yyyy)
income has been paid/credited

12. Date of declaration, distribution or payment of dividend/withdrawal under the 13. Account Number of National Savings Scheme from which withdrawal has
National Savings Scheme (dd/mm/yyyy) N.A. been made N.A.

Forwarded to the Chief Commissioner or Commissioner of Income Tax ………………………………………………………………………

Place: ………………………………….. ________________________________

Date: …………………………………… Signature of the person responsible for
paying the income referred to in Column
22 of Part I

NOTES

1. The declaration should be furnished in triplicate.

2. *Delete whichever is not applicable.
3. #Declaration can be furnished by an individual under Section 197A(1) and a person (other than a company or a firm) under Section 197A(1A).

4. **Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
5. 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 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.
6. The person responsible for paying the income referred to in Column 22 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.

TO BE FILLED BY THE BRANCH

Checklist for Form 15 (G) for Individuals less than 60 years of age
I have checked and confirmed the below: Tick
1. Customer is <60 years (if >=60 years then fill form 15 H)
2. PAN is updated in Bank Records against the Customer ID of customer
3. Copy of PAN Card attached along with Account Maintenance Form (if not updated in the system)
4. Customer has signed in six places (indicated by ⊗)

Name of Employee ___________________ Employee Code ________________

Employee Signature Date:

Branch Stamp
Version No. 4.0 – 17th April 2013 (Income Tax Copy)

FORM 15 (G)
See Section 197A(1), Section 197A(1A) and Rule 29(C)

Declaration under Section 197A(1) and Section 197A(1A) of the Income-tax Act, 1961,
to be made by an individual or a person (not being a company or a firm) claiming certain receipts without deduction of tax

Customer ID

PART I

1. Name of Assessee (Declarant) 2. PAN of the Assessee

3. Assessment Year
(for which declaration is being made)
4. Flat / Door / Block No. 5. Name of Premises 6. Status
7. Assessed in which Ward / Circle
8. Road / Street / Lane 9. Area / Locality 10. AO Code (under whom assessed last time)

Area Code AO Type Range Code AO no.

11. Town / City / District 12. State
13. PIN 14. Last Assessment Year in which assessed

15. Email 16. Telephone No. (with STD code) and 17. Present Ward / Circle
Mobile No. 18. Residential status (within the meaning of Section 6 of
Income Tax Act 1961
19. Name of Business / Occupation
20. Present AO Code (if not the same as above)

21. Jurisdictional Chief Commissioner of Income Tax or Commissioner of Income Area Code AO Type Range Code AO no.
Tax (if not assessed to Income Tax earlier)
22. Estimated total income from the sources mentioned below:
(Please tick the relevant box)
Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Interest from units referred to in Schedule IV
The amount of withdrawal referred to in Section 80CCA(2)(a) from National Savings Scheme referred to in Schedule V
23. Estimated total income from the previous year in which income mentioned in Column 22 is to be included

24. Details of investment in respect of which the declaration is being made:

Schedule I (Details of shares which stand in the name of the declarant and beneficially owned by him)
Number of Shares Class of shares and face Total face value of Distinctive numbers Date(s) on which the shares were acquired by the
value of each share shares of the shares declarant (dd/mm/yyyy)

Schedule II (Details of securities which stand in the name of the declarant and beneficially owned by him)
Description of Number of securities Date(s) of securities Amount of securities Date(s) on which the securities were acquired by
securities (dd/mm/yyyy) the declarant (dd/mm/yyyy)

Schedule III (Details of the sums given by the declarant on interest)

Name and Address of the person to Amount of such sums Date on which sums were given Period for which such sums Rate of Interest
whom the sums are given on interest given on interest on interest (dd/mm/yyyy) were given on interest

Schedule IV (Details of mutual fund units which stand in the name of the declarant and beneficially owned by him)
Name and Address of the Number of units Class of units and face Distinctive number of units Income in respect of units
Mutual Fund value of each unit

Schedule V (Details of the withdrawal made from National Savings Scheme)

Particulars of the post office where the account Date on which the account was opened The amount of withdrawal from the account
under the National Savings Scheme is (dd/mm/yyyy)
maintained and the account number

_____________________________⊗
Signature of Declarant
 (Income Tax Copy)

Declaration / 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. *I/We declare that the incomes referred to in this form are not includible in the total income of any other person under section 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 22 above, computed in
accordance with the provisions of the Income Tax Act 1961, for the previous year ending on …………………..relevant to the assessment year …………………….will be nil.
*I/We also declare that *my/our *income/incomes referred to in Column 22 for the previous year ending on …………………..relevant to the assessment year
…………………….will not exceed the maximum amount which is not chargeable to Income Tax.

Place: ………………………………….. _____________________________⊗

Date: …………………………………… Signature of Declarant

PART II [For use by the person to whom the declaration is furnished]

1. Name of the person responsible for paying the income referred to in Column 22 2. PAN of the person indicated in Column 1 of Part II
of Part I YES BANK LTD. AAACY2068D
3. Complete Address YES BANK LTD., Nehru Centre, 9th floor, Discovery of
India, Dr. A. B. Road, Worli, Mumbai - 400018 4. TAN of the person indicated in Column 1 of Part II
5. Email 6. Telephone No. (with STD Code) and MUMY02084F
Mobile No. (22) 66699000 7. Status Domestic Company
8. Date on which Declaration is 9. Period in respect of which the 10. Amount of income paid 11. Date on which income has been
furnished (dd/mm/yyyy) dividend has been declared or the paid/credited (dd/mm/yyyy)
income has been paid/credited

12. Date of declaration, distribution or payment of dividend/withdrawal under the 13. Account Number of National Savings Scheme from which withdrawal has
National Savings Scheme (dd/mm/yyyy) N.A. been made N.A.

Forwarded to the Chief Commissioner or Commissioner of Income Tax ………………………………………………………………………

Place: ………………………………….. ________________________________

Date: …………………………………… Signature of the person responsible for
paying the income referred to in Column
22 of Part I

NOTES

1. The declaration should be furnished in triplicate.

2. *Delete whichever is not applicable.
3. #Declaration can be furnished by an individual under Section 197A(1) and a person (other than a company or a firm) under Section 197A(1A).

4. **Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
5. 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-
(iii) 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;
(iv) 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.
6. The person responsible for paying the income referred to in Column 22 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.

DISCLAIMER

1. Form 15G is to be filled only for Individuals less than 60 years (if >=60 yrs then fill Form 15H), Proprietorship,
Society, Associations of Persons, Trust, HUF etc
2. TDS waiver will not be marked if PAN details are not updated on the Bank’s records
3. TDS waiver will be marked from the date of submission of this form Branch Seal with
4. TDS which has already been deducted will not be refunded back and to be sought from Income Tax Department signature and date
5. A fresh Form 15G needs to be submitted in each new Financial Year within the start of the Financial Year
6. Form 15G needs to be submitted in Triplicate
7. Form 15G needs to be submitted for every Fixed Deposits booked with the Bank
8. The Bank shall not be liable for any consequences or loss arising due to delay or non or wrong submission of
Form 15G
9. I/We fully understand that wrong quoting of PAN may result in penal consequences under section 272B of Income
Tax act 1961 and the bank is not responsible for any consequences arising due to wrong quoting of PAN
Version No. 4.0 – 17th April 2013 (Customer Copy)

FORM 15 (G)
See Section 197A(1), Section 197A(1A) and Rule 29(C)

Declaration under Section 197A(1) and Section 197A(1A) of the Income-tax Act, 1961,
to be made by an individual or a person (not being a company or a firm) claiming certain receipts without deduction of tax

Customer ID

PART I

1. Name of Assessee (Declarant) 2. PAN of the Assessee

3. Assessment Year
(for which declaration is being made)
4. Flat / Door / Block No. 5. Name of Premises 6. Status
7. Assessed in which Ward / Circle
8. Road / Street / Lane 9. Area / Locality 10. AO Code (under whom assessed last time)

Area Code AO Type Range Code AO no.

11. Town / City / District 12. State
13. PIN 14. Last Assessment Year in which assessed

15. Email 16. Telephone No. (with STD code) and 17. Present Ward / Circle
Mobile No. 18. Residential status (within the meaning of Section 6 of
Income Tax Act 1961
19. Name of Business / Occupation
20. Present AO Code (if not the same as above)

21. Jurisdictional Chief Commissioner of Income Tax or Commissioner of Income Area Code AO Type Range Code AO no.
Tax (if not assessed to Income Tax earlier)
22. Estimated total income from the sources mentioned below:
(Please tick the relevant box)
Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Interest from units referred to in Schedule IV
The amount of withdrawal referred to in Section 80CCA(2)(a) from National Savings Scheme referred to in Schedule V
23. Estimated total income from the previous year in which income mentioned in Column 22 is to be included

24. Details of investment in respect of which the declaration is being made:

Schedule I (Details of shares which stand in the name of the declarant and beneficially owned by him)
Number of Shares Class of shares and face Total face value of Distinctive numbers Date(s) on which the shares were acquired by the
value of each share shares of the shares declarant (dd/mm/yyyy)

Schedule II (Details of securities which stand in the name of the declarant and beneficially owned by him)
Description of Number of securities Date(s) of securities Amount of securities Date(s) on which the securities were acquired by
securities (dd/mm/yyyy) the declarant (dd/mm/yyyy)

Schedule III (Details of the sums given by the declarant on interest)

Name and Address of the person to Amount of such sums Date on which sums were given Period for which such sums Rate of Interest
whom the sums are given on interest given on interest on interest (dd/mm/yyyy) were given on interest

Schedule IV (Details of mutual fund units which stand in the name of the declarant and beneficially owned by him)
Name and Address of the Number of units Class of units and face Distinctive number of units Income in respect of units
Mutual Fund value of each unit

Schedule V (Details of the withdrawal made from National Savings Scheme)

Particulars of the post office where the account Date on which the account was opened The amount of withdrawal from the account
under the National Savings Scheme is (dd/mm/yyyy)
maintained and the account number

_____________________________⊗
Signature of Declarant
 (Customer Copy)

Declaration / 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. *I/We declare that the incomes referred to in this form are not includible in the total income of any other person under section 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 22 above, computed in
accordance with the provisions of the Income Tax Act 1961, for the previous year ending on …………………..relevant to the assessment year …………………….will be nil.
*I/We also declare that *my/our *income/incomes referred to in Column 22 for the previous year ending on …………………..relevant to the assessment year
…………………….will not exceed the maximum amount which is not chargeable to Income Tax.

Place: ………………………………….. _____________________________⊗

Date: …………………………………… Signature of Declarant

PART II [For use by the person to whom the declaration is furnished]

1. Name of the person responsible for paying the income referred to in Column 22 2. PAN of the person indicated in Column 1 of Part II
of Part I YES BANK LTD. AAACY2068D
3. Complete Address YES BANK LTD., Nehru Centre, 9th floor, Discovery of
India, Dr. A. B. Road, Worli, Mumbai - 400018 4. TAN of the person indicated in Column 1 of Part II
5. Email 6. Telephone No. (with STD Code) and MUMY02084F
Mobile No. (22) 66699000 7. Status Domestic Company
8. Date on which Declaration is 9. Period in respect of which the 10. Amount of income paid 11. Date on which income has been
furnished (dd/mm/yyyy) dividend has been declared or the paid/credited (dd/mm/yyyy)
income has been paid/credited

12. Date of declaration, distribution or payment of dividend/withdrawal under the 13. Account Number of National Savings Scheme from which withdrawal has
National Savings Scheme (dd/mm/yyyy) N.A. been made N.A.

Forwarded to the Chief Commissioner or Commissioner of Income Tax ………………………………………………………………………

Place: ………………………………….. ________________________________

Date: …………………………………… Signature of the person responsible for
paying the income referred to in Column
22 of Part I

NOTES

1. The declaration should be furnished in triplicate.

2. *Delete whichever is not applicable.
3. #Declaration can be furnished by an individual under Section 197A(1) and a person (other than a company or a firm) under Section 197A(1A).

4. **Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
5. 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-
(v) 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;
(vi) 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.
6. The person responsible for paying the income referred to in Column 22 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.

DISCLAIMER

1. Form 15G is to be filled only for Individuals less than 60 years (if >=60 yrs then fill Form 15H), Proprietorship,
Society, Associations of Persons, Trust, HUF etc
2. TDS waiver will not be marked if PAN details are not updated on the Bank’s records
3. TDS waiver will be marked from the date of submission of this form Branch Seal with
4. TDS which has already been deducted will not be refunded back and to be sought from Income Tax Department signature and date
5. A fresh Form 15G needs to be submitted in each new Financial Year within the start of the Financial Year
6. Form 15G needs to be submitted in Triplicate
7. Form 15G needs to be submitted for every Fixed Deposits booked with the Bank
8. The Bank shall not be liable for any consequences or loss arising due to delay or non or wrong submission of
Form 15G
9. I/We fully understand that wrong quoting of PAN may result in penal consequences under section 272B of Income
Tax act 1961 and the bank is not responsible for any consequences arising due to wrong quoting of PAN