FORM NO. 121

 

[See rule 211]

Declaration under section 393(6) for receipt of certain incomes without deduction of tax

[To be Filled by the person for receipt of certain incomes without deduction of tax]

Details of the declarant
1.	Name				(refer Note 1)
2.	Address				(refer Note 2)
3.	Permanent Account Number
4.	Status				(refer Note 3)
5.	Residential status				(refer Note 4)
5(a).	If resident individual, whether age is 60 years or more at any time during the tax year				Yes/no
6.	Email id
7.	Contact number				Country Code	Number
8.	Tax Year (for which declaration is made)
Details of income
9.	Nature of income				(refer Note 5)
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				(refer Note 6)
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				(refer Note 7)
14.	Details of the ITR filed for previous two tax years
	Sl. No.	Tax Year	Acknowledgment Number	Return Income
	1.
	2.

• 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: …………

Signature of the Declarant

Date: …………

Name:

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	(refer Note 1)
2.	Address	(refer Note 2)
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	(refer Note 1)
9.	Permanent Account Number
10.	Unique Identification Number
11.	Date of Birth/Incorporation	(dd/mm/yyyy)
12.	Address	(refer Note 2)
13.	Email id
14.	Contact number	Country Code	Number
15.	Estimated income for which declaration is made	(as per column 10 of Part A)
16.	Estimated total income of the tax year of the declarant	(as per column 13 of Part A)
17.	Aggregate amount of income for which declaration is made during the tax year	(as per column 12 of Part A)
18.	Date on which declaration is received	(dd/mm/yyyy)

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.

Place: …………

Signature of the authorized person

Date: …………

Name:

• 1.
  In case of individual, the first, middle and last name shall be provided in full without any abbreviations. In any other case also, name shall be provided in full.
• 2.
  The address shall contain i. Country/Region, ii. Flat/Door/Building, iii. Road/Street/ Block/Sector, iv. PIN/ZIP Code, v. Post Office, vi. Area/locality, vii. District, viii. State.
• 3.
  Declaration can be furnished by an individual being a resident under section 393(6) [Table: Sl. No. 1] or by any person, not being a company or a firm or an individual covered in section 393(6)[Table: Sl. No. 1], under section 393(6)[Table: Sl. No. 2].
• 4.
  Fill ‘residential status’ as (i) Resident (ii) Non-resident (iii) Resident but not ordinarily resident.
• 5.
  This application is applicable for following incomes, please fill 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 specified person
  • (d)
    income in respect of (i) units of a mutual fund, or (ii) units from the Administrator of the specified undertaking, or (iii) units from the specified 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 office for a deposit made under a scheme notified by the Central Government or by Specified 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.

• 6.
  In case any declaration(s) in Form No, 121 is filed before filing this declaration during the tax year, mention the total number of such Form No. 121 filed along with the total amount of income for which said declaration(s) have been filed.
• 7.
  Please mention amount of estimated total income of the tax year for which declaration is filed including the amount of income for which this declaration and earlier declaration(s), if any, is made.
• 8.
  The person responsible for paying income referred to in row no. 10 of Part A shall allot a unique identification 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.
• 9.
  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.
• 10.
  Estimated total income shall be calculated after allowing for deduction(s) under Chapter VIII of the Act, if any, or set off of loss, if any, under the head “Income from house property” and rebate allowable under section 156.
• 11.
  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.
• 12.
  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 482.
• 13.
  Some of the information in the form would be pre-filled to the extent possible.
• 14.
  Amounts to be filled in ₹ unless otherwise provided.