Instructions: Fill only Part A of Form 121, Part B of Form 121 will be filled by authorised person. Use Desktop version of site while using this utility on mobile. See Notes in the last of this page for help in filling.
FORM NO. 121
[See rule 211]
Declaration under section 393(6) for receipt of certain incomes without deduction of tax
PART A
[To be Filled by the person for receipt of certain incomes without deduction of tax]
Details of the declarant
| 1. | Name | ||||
| 2. | Address | ||||
| 3. | Permanent Account Number | ||||
| 4. | Status | ||||
| 5. | Residential status | ||||
| 5(a). | If resident individual, whether age is 60 years or more at any time during the tax year | ||||
| 6. | Email id | ||||
| 7. | Contact number (Use Country Code as +91 for India) | Country Code: | Number: | ||
| 8. | Tax Year (for which declaration is made) | ||||
Details of income
| 9. | Nature of income | ||||
| 10. | Estimated income for which declaration is made | ||||
| 11. | Details of Form No. 121 other than this form filed during the tax year, if any | ||||
| 11(a). | Total number of Form No. 121 filed earlier | ||||
| 11(b). | Aggregate amount of income for which Form No. 121 were filed | ||||
| 12. | Aggregate amount of income for which declaration is made during the tax year[sum of column 10 and 11(b)] | ||||
| 13. | Estimated total income of the tax year including the income mentioned in column 12 | ||||
| 14. | Details of the ITR filed for previous two tax years | ||||
| Sl. No. | Tax Year | Acknowledgement Number | Return Income |
|---|---|---|---|
| 1. | |||
| 2. |
DECLARATION
I, ________________ having Permanent Account Number ________________ do hereby declare that:
(i) to the best of my knowledge and belief what is stated above is correct, complete and is truly stated.
(ii) the incomes referred to in this form are not includible in the total income of any other person under sections 96 to 99.
(iii) tax on my estimated total income as referred to in column 13 of Part A (including the income referred to in column 12 of Part A) for tax year ________ will be nil.
(iv) my income as referred to in column 12 of Part A does not exceed the maximum amount not chargeable to tax for tax year ________ (not to be applicable in case of resident individual of age of sixty years or more at any time during the tax year)
(v) in case this declaration is found to be false, I shall be liable to prosecution/penalty under the Act.
I, ________________ having Permanent Account Number ________________ do hereby declare that:
(i) to the best of my knowledge and belief what is stated above is correct, complete and is truly stated.
(ii) the incomes referred to in this form are not includible in the total income of any other person under sections 96 to 99.
(iii) tax on my estimated total income as referred to in column 13 of Part A (including the income referred to in column 12 of Part A) for tax year ________ will be nil.
(iv) my income as referred to in column 12 of Part A does not exceed the maximum amount not chargeable to tax for tax year ________ (not to be applicable in case of resident individual of age of sixty years or more at any time during the tax year)
(v) in case this declaration is found to be false, I shall be liable to prosecution/penalty under the Act.
Place:
Date:
Date:
Signature of the Declarant
Name:
Name:
FORM NO. 121
PART B
[Verification by the person who has received declaration(s) in Part-A from the declarant(s) and responsible for paying the income in respect of which this declaration is made]
Details of the person responsible for paying income
| 1. | Name | |||
| 2. | Address | |||
| 3. | Tax Deduction and Collection Account Number | |||
| 4. | Permanent Account Number | |||
| 5. | Email id | |||
| 6. | Contact number | Country Code: | Number: | |
| 7. | Tax Year | |||
Details of the declarant and the declarations received
| 8. | Name of the declarant | |||
| 9. | Permanent Account Number | |||
| 10. | Unique Identification Number(Adhar Number) | |||
| 11. | Date of Birth/Incorporation | |||
| 12. | Address | |||
| 13. | Email id | |||
| 14. | Contact number | Country Code: | Number: | |
| 15. | Estimated income for which declaration is made | |||
| 16. | Estimated total income of the tax year of the declarant | |||
| 17. | Aggregate amount of income for which declaration is made during the tax year | |||
| 18. | Date on which declaration is received | |||
DECLARATION
I (name of authorized person) having Permanent Account Number hereby certify that the information pertaining to the declarant(s) above has been duly furnished.
I (name of authorized person) having Permanent Account Number hereby certify that the information pertaining to the declarant(s) above has been duly furnished.
Place:
Date:
Date:
Signature of the authorized person
Name:
Name:
Notes:
- In case of individual, the rst, middle and last name shall be provided in full without any abbreviations. In any other case
also, name shall be provided in full. - The address shall contain i. Country/Region, ii. Flat/Door/Building, iii. Road/Street/ Block/Sector, iv. PIN/ZIP Code, v. Post
O ce, vi. Area/locality, vii. District, viii. State. - Declaration can be irnished by an individual being a resident under section 393(6)[Table: Sl. No. 1] or by any person, not
being a company or a rm or an individual covered in section 393(6)[Table: Sl. No. 1], under section 393(6)[Table: Sl. No. 2]. - Fill ‘residential status’ as (i) Resident (ii) Non-resident (iii) Resident but not ordinarily resident.
- This application is applicable for following incomes, please ll as applicable:
(a) payment of accumulated balance due to an employee participating in recognized provident fund
(b) insurance commission for soliciting or procuring insurance business including business related to continuance,
renewal, or revival of the insurance policies.
(c) rent from a speci ed person
(d) income in respect of(i) units of a mutual fund, or (ii) units from the Administrator of the speci ed undertaking, or (iii)
units from the speci ed company
(e) interest on securities, interest other than interest on securities by a banking company or a co-operative society
carrying on the business of banking or interest by a post o ce for a deposit made under a scheme noti ed by the
Central Government or by Speci ed person
(f) payment in respect of life insurance policy including the sum allocated as bonus on such policy
(g) dividend (including dividend on preference shares) declared by domestic company
Refer Section 393(6) for more details. - In case any declaration(s) in Form No, 121 is led before ling this declaration during the tax year, mention the total
number of such Form No. 121 led along with the total amount of income for which said declaration(s) have been led. - Please mention amount of estimated total income of the tax year for which declaration is led including the amount of
income for which this declaration and earlier declaration(s), if any, is made. - The person responsible for paying income referred to in row no. 10 of Part A shall allot a unique identi cation number to
all Form No. 121 received by him during a quarter of the tax year and report the same in TDS statement furnished for the
same quarter. - The person responsible for paying income referred to in row no. 10 of Part A shall accept the declaration where the tax on
declarant’s estimated total income as referred to in row no. 13 of Part A of the tax year will be nil. - Estimated total income shall be calculated after allowing for deduction(s) under Chapter VIII of the Act, if any, or set o of
loss, if any, under the head “Income from house property” and rebate allowable under section 156. - For a declarant other than the resident individual whose age is 60 years or more at any time during the tax year, the person
responsible for paying income referred to in row no. 10 of Part A shall not accept the declaration where the amount of
income of the nature referred to in section 393(6) or total amount of such income credited or paid or likely to be credited
or paid during the tax year in which such income is to be included exceeds the maximum amount which is not chargeable
to tax. - Before signing the veri cation, 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 482. - Some of the information in the form would be pre- lled to the extent possible.
- Amounts to be lled in ` unless otherwise provided