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 ( refer Note 1 )
2. Address ( refer Note 2 )
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. Permanent Account Number (PAN)
4. Status ( refer Note 3 )
5. Residential status ( refer Note 4 )
If resident individual, whether age is 60 years or more at any time during the tax
5(a).
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 filed earlier during the tax year (Yes/No)
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 ₹ (10 + 11(b))
13 . Estimated total income of the tax year including income mentioned in column 12
14 . Details of last of the ITR filed for previous two tax years (Latest FY for which Return Filed)
Acknowledgment
Sr. No. Tax Year Return Income
Number
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 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 of the Act.
(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 2026-27 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 2026-27 (not
applicable in case of resident individual of age of sixty years or more).
(v) In case this declaration is found to be false, I shall be liable to prosecution/penalty under the Act.
Place: ____________
Date: ____________
Signature of the Declarant: ____________________
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 Axis Bank Ltd.
2. Address Axis Bank Ltd, Gigaplex,
6th Floor, Airoli, Navi Mumbai -400708
3. Tax Deduction and Collection Account Number (TAN) MUMU05151G
4. Permanent Account Number (PAN) AAACU2414K
5. Email id
6. Contact number (Country Code & Number)
7. Tax Year 2026-2027
Details of the declarant and declarations received
8. Name of the declarant (refer Note 1)
9. Permanent Account Number (PAN) of declarant
10 . Unique Identification Number
11 . Date of Birth/Incorporation (dd/mm/yyyy)
12 . Address of declarant (refer Note 2)
13 . Email id of declarant
14 . Contact 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/We Axis Bank having Permanent Account Number AAACU2414K hereby certify that the information pertaining to the declarant(s) above has
been duly furnished as received in Part-A from the declarant(s) and is accurately reported to the best of my knowledge and belief.
Place: ____________ Signature of the person responsible for paying the income: ____________________
Date: ____________ Name: ____________________
Notes :
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 resident under section 393(6) [Table: [Link]. 1] or by any person not being a company or a
firm or an individual covered in section 393(6) [Table: [Link].1] under section 393(6) [Table:[Link].2]
4. Fill “residential status” as: (i) Resident (ii) Non-resident (iii) Resident but not ordinarily resident.
5. Applicable incomes (fill as applicable):
(a) payment of accumulated balance due to an employee participating in recognized provident fund;
(b) insurance commission;
(c) rent from a specified person;
(d) income in respect of units of a mutual fund/Administrator of the specified undertaking/the specified company;
(e) interest on securities/interest other than securities by a banking company/co-operative society carrying on the business of banking or interest
by a post office for a deposit made under a notified scheme/by specified person;
(f) payment in respect of life insurance policy including bonus;
(g) dividend (including dividend on preference shares) declared by domestic company.
6. In case any declaration(s) in Form No.121 is filled 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
[Link] person responsible for paying income reffered to in row no.10 of Part A shall allot a unique identification number to all Form 121 received
by him during the quarterof the tax year and report the same in TDS statement furnished for the same quarter.
9. The person responsible for paying income reffered to in row no. 10 of Part A shall accept the declaration where the tax on declarant's estimated
total income as reffered 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 reffered to in row no.10 of Part A shall not accept the declaration where the amount of income of the nature reffered 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 Rs. unless otherwise provided.