FORM NO. 15D
[See rule 29B]
Application by a person other than a banking company for a certificate under section
195(3) of the Income-tax Act, 1961, for receipt of sums other than interest
and dividends without deduction of tax
To
The Assessing Officer,
…………………………..
…………………………..
Sir,
I, …………………………………, being the principal officer of....................................……..,
we....................................………………………………………………………………………...................
[name of the person, firm or company untitled to receive sums other than interest and dividends]
do hereby declare:
(a) that I/…………………………………………………………………………………….
[name of the firm, company, etc.]
am/is a non-resident assessee (not being a banking company) carrying on business/
profession in India through a branch(es) by name(s) ..............................…………………
having office(s) at......................................;
(b) that my head office/the head office of....................................…………………………..
[name of the firm, company, etc.]
is situated at ......................................................................................................................
[name of the place and country]
(c) that I/.................................................................................................................................
[name of the firm, company, etc.]
am/is entitled to receive income (other than dividends and interest) chargeable under the provisions
of the Income-tax Act, 1961, during the financial year …...... - ….......;
(d) that I/.................................................................................................................................
[name of the firm, company, etc.)
fulfil(s) all the conditions laid down in rule 29B of the Income-tax Rules, 1962.
I, therefore, request that a certificate may be issued authorising me/............................................................
.......................................................................................................................................................................
[name of the firm, company, etc.]
to receive income other than interest or dividends without deduction of tax under sub-section (1) of section
195 of the Income-tax Act, 1961, during the financial year ....... - ........
I hereby declare that what is stated in this application is correct.
Date .......................
 ………………………..
Signature
………………………..
………………………..
Address