FORM NO. 15B
[See rule 30A(2)] Form of declaration to be made by the registered shareholder and by the person claiming credit where the dividend on the share is assessable as the income of such other person
I/We hereby declare that dividend(s)as per details shown in columns 4 to 7 of the Table herein below on the share(s)specified in column 3 thereof registered in my/our name(s)/the name of…………..name of the bank/company etc.] wascollected by me/us………………. [the bank/company etc.] on behalf of…………………….[name and address] who is/which is beneficially entitled to receive the income by way of dividend. Particulars of the tax deducted at source from the dividend(s) mentioned hereinabove, as shown in the certificate of deduction of tax under section 203 issued in my/our name……………[name of the bank/company etc.] are given in columns 8 to 10 of the Table hereinbelow.
I/We further declare that I/we………………the bank/company etc.] has/have not claimed any credit under section 199, nor has any credit under that section been allowed to me/us…………………..[the bank/company etc.] for the tax deducted from the dividend(s) on these shares.
I/We also undertake that I/we………………..[the bank/company etc.] shall not claim any credit under section 199 for the tax deducted at source from the dividend(s) on these shares.
Date.....................
Signature of the share holder .
Address ............................
TABLE
GIVING DETAILS OF DIVIDENDS, SHARES ETC.
Sl. No.
Name of company paying the dividend
No., description and face value of shares
Date of declaration of the dividend
Date of receipt of dividend
Period for which dividend declared
Amount of dividend
Tax deducted under section 194 of the Income-tax Act, 1961
IT
SC
Total
Net amount received
Particulars of certificate of deduction of tax under section 203
1
2
3
4
5
6
7
8
9
10
11
12
I/We hereby declare that dividend(s)as per details shown in columns 4 to 7 of the above Table, on the share(s)specified in column 3 thereof is/are assessable as………………………………………….……………..[my /our income ] / [the income of the]………………………[name of the bank/company etc.] At the time when dividend on the above mentioned share(s) was declared/credited/paid these shares were registered in the name(s) of………………[name and address] and the dividend thereon was collected by the said………………….[on my/our behalf]/………………….[ on behalf of the bank/company etc.].
I/We therefore request that for the reasons given hereunder the credit in respect of the tax deducted at source from the dividend mentioned above should be given to…………………[me/us ][ the bank/company etc.]……………………
[Reasons to be stated]
