Fill the form, sign in the box, then use Print → choose “Save as PDF” for an electronic copy, or print on paper. Column 12 totals itself from 10 and 11(b); the declaration mirrors Name, PAN and Tax Year automatically.

FORM NO. 121
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 (DOB)
DOB:
6. Email id
7. Contact number
Country CodeNumber
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 last of the ITR filed for previous two tax years
Sl. No.Tax YearAcknowledgment NumberReturn Income
1.
2.
DECLARATION

I, ………………………… having Permanent Account Number …………… do hereby declare that—

  1. to the best of my knowledge and belief what is stated above is correct, complete and is truly stated.
  2. 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.
  3. 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.
  4. 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)
  5. 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
Signature of the Declarant
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. Fill ‘person’ status as (i) Individual (ii) Hindu undivided family (iii) Company (iv) Firm (v) Association of persons, whether incorporated or not (vi) Body of individuals, whether incorporated or not (vii) Local Authority (viii) Artificial Juridical Person (ix) Government (x) Trust
  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. 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 of the Act.
  7. Some of the information in the form would be pre-filled to the extent possible.
  8. Amounts to be filled in ₹ unless otherwise provided.