1FORM 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) 2. PAN of the Assessee1
Debargha Roy Chaudhury AVJPR4827Q
3. Status2 4. Previous year(P.Y.)3 2025-26 5. Residential Status4
Individual (for which declaration is being made) Resident
6. Flat/Door/Block No. 7. Name of Premises 8. Road/Street/Lane 9. Area/Locality
B-27 Laxmikunj Society New Sama Road Opp. Nutan School
10. Town/City/District 11. State 12. PIN 13. Email
Vadodara Gujarat 390024 droychaudhury@gmai
l.com
14. Telephone No. (with STD Code) and Mobile No.
15 (a) Whether assessed to tax under the Income-tax Act, 19615: Yes No No
(b) If yes, latest assessment year for which assessed
16. Estimated income for which this declaration is made 11397
17. Estimated total income of the P.Y. in which income mentioned in 250000
column 16 to be included6
18. Details of Form No. 15G other than this form filed during the previous year, if any7
Total No. of Form No. 15G filed Aggregate amount of income for which Form No.15G
filed
0 0
19. Details of income for which the declaration is filed
S l . Identification number Nature of income Section under which Amount of income
No. of relevant investment/ tax is deductible
account, etc. 8
DLCPM0036080000 PF Withdrawal 192A 11397
0027822
...............................................................
Signature of the Declarant9
_________________________
1. Substituted by IT (Fourteenth Amdt.) Rules, 2015, w.e.f. 1-10-2015. Earlier Form No. 15G was
inserted by the IT (Fifth Amdt.) Rules, 1982, w.e.f. 21-6-1982 and later on amended by the IT
(Fifth Amdt.) Rules, 1989, w.r.e.f. 1-4-1988, IT (Fourteenth Amdt.) Rules, 1990, w.e.f. 20-11-1990
and IT (Twelfth Amdt.) Rules, 2002, w.e.f. 21-6-2002 and substituted by the IT (Eighth Amdt.)
Rules, 2003, w.e.f. 9-6-2003 and IT (Second Amdt.) Rules, 2013, w.e.f. 19-2-2013.
Declaration/Verification10
*I/We .Debargha Roy Chaudhury 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 .........2025-26..................... relevant to the assessment year .......2026-27.......................
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
......2025-26........................ relevant to the assessment year ........2026-27...................... will not exceed
the maximum amount which is not chargeable to income-tax.
Place: ..........Vadodara..................... .......................Debargha.............
Date: .........03/09/2025............................... Signature of the Declarant9
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 2. Unique Identification No.11
paying
3. PAN of the person 4. Complete Address 5. TAN of the person
responsible for paying responsible for paying
6. Email 7. Telephone No. (with STD Code) 8. Amount of income paid12
and Mobile No.
9. Date on which Declaration is 10. Date on which the income has been
received (DD/MM/YYYY) paid/credited (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.
1. As 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).
2. 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).
3. The financial year to which the income pertains.
4. Please mention the residential status as per the provisions of section 6 of the Income-tax Act, 1961.
5. Please 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.
6. Please 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.
7. In 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.
8. Mention the distinctive number of shares, account number of term deposit, recurring deposit, National
Savings Schemes, life insurance policy number, employee code, etc.
9. Indicate the capacity in which the declaration is furnished on behalf of a HUF, AOP, etc.
10. Before 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.
11. The 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.
12. The 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.
