FORM NO. 15
[See rule 29]
Certificate under section 197(1) of the Income tax Act, 1961, relating to deduction of tax from dividends
Certificate No.                                                             Income-tax Office,        
Date    
To
The Principal Officer,
[name of company]
[address of company]
I hereby authorise you to pay without deduction of income-tax the dividend, payable by your company on the undermentioned shares registered in the name of
2. I hereby authorise you to pay the dividend payable by your company on the undermentioned shares registered in the name of……………..after deducting income-tax at the rate of………. …………per cent and surcharge at the rate of………….per cent of the amount of the dividend.
3. This certificate shall remain in force up to…………..unless it is cancelled by me under intimation to you, before that date.
4. The certificate shall cease to be operative in respect of any of the shares mentioned herein which are transferred by the present holder to any other person, from the date the company receives notice of such transfer.
DESCRIPTION OF SHARES

SI. No.	No. of shares	Class and face value of each share	Total face value of shares	Distinctive Nos. of shares
1	2	3	4	5

(SEAL)                                                                                               Assessing Officer