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FORMN0.121
[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]
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Details of the declarant
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~!Name RAHUL T (rc>ccr f lot£ 1J
2.
- Address No. ~ . 4-~ r 1().((. h. I) Pl:..t'\ ( ,, I II"\"+-
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3. Permanent Account Number '
4.
-, Status
- [Link],rl I In l (refer Notn ~)
'--
5. Residential status
- Re.s\d.e nt {,erer f-/()1 A
S(a). If resident individual, whether age is 60 years or more at
any time during the tax year -
Yes/no
6. Email id (S'Qhul d.a..t.t o(o) 9'MOJ \. CoW"\
7. Contact number Country Code Number
--=,gqQ. 59 5Go2-
- 91
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I
8.
9.
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Tax Year (for which declaration is made)
Nature of income
Details of income
2026 - 202-=1-
(( &rorfic) t e s}
10. Estimated income for which declaration is made REf\J"T - 5 4,E>OO
11. Details of Form No. 121 other than this form filed during (rwr N°tc (.}
the tax year, if any
11 (a). Total number of Form No. 121 filed earlier /\Jill
r 11 (b). Aggregate amount of income for which Form No. 121 were filed Ni 1'
1-
Aggregate amount of income for which declaration is made
I
12.
during the tax year [sum of column 10 and 1 l(b)] (\) i'I I I
I
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13.
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Estimated total income of the tax year including the income
mentioned in column 12 b,ocfoo6. ~ ---~
14. -+-Details of the ITR filed for previous two tax years N;I)
SI. No.
I
Tax Year , Acknowledgment Return I
I Number Income '
-1 - l
1.
' 2.
- ! i
I
~
DECLARATION
(< R HCJ L , (3:f PP,6461H
I ............................................................... having Permanent Account Number............................................ao 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 Al 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.~~::.?.:?,i~;ro be applicable in case of resident individual ofage ofsixty years or more at any time during the tax year)
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y under the Act.
lv) in case this declaration is found to be false, I shall be liable to prosecuti on/penalt
--r=:d \ ---'t\/
Signature of the Declarant
Place: J:½.~~ Y\)
Date: .. '9../'2./~ 02.6 Name: f<.. A H U L I
PARTB
declarant(s) and responsible for paying
[Verificat ion by the person who has received declaration(s) in Part-A from the
the income in respect of which this declaratio n is made]
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Details of the person responsible for paying income
___r_,e_fi_e_,_N_o_to_1J_ _ _ _--i
1. ] "_ Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _-+-___
r 2. J Address
(r<'fcr Note 2)
3. Tax Deduction and Collection Account Number
4. Permanent Account Number
5. Email id
I
Country Code Number
I 6. Contact number
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7. Tax Year
,-~----- Details of the declarant and the declarations received
I -----------------1
~----.-----------------------------,- (n.,fer fvote 1)
8. Name of the declarant
9. Permanen t Account Number
10. Unique Identifica tion Number l
I
(dd/mm/yyy_y)
11. Date of Birth/Inco rporation
I
{refer Note 2)
12. Address
13. Email id
Contact number Country Code Number
14.
(as per column 10 of [Link] A)
l
Estimated income for which declaratio n is made
15.
- - i - - - - - - - - - - - -tax-year -----------~
- - - - - - - - - - - - : t - -(as
of the declarant pcrcolt1m n 13 of Part Ai
16. Estimated total income of the
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1?. of Part/\) (as per rolumn
17. Aggregate amount of income for which declaration is made
during the tax year
18. Date on which declaratio n is received (ddlmm/y yyyl
DECLARATION
..................... hereby certify that the
I (name of authorize d person) ................... having Permanent Account Number ................
informatio n pertaining to the declarant(s) above has been duly furnished.
Place: .......... .. Signature of the authorized person
Date: ........... . Name:
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