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The Schedule
[See Section 7(2)]
Form of Declaration
(To Be Filled In Triplicate)

1. Name of the owner of the bank notes (In block letters)

2. Address: Office Residence

3. Status, i,e., whether individual, Hindu undivided family, company, firm, etc.

4. (a) Whether assessed to income-tax;

(b) If so, name of the Income-Tax Circle/Ward/District where last assessed;

(c) Permanent Account Number.

5. If engaged in business, profession or vocation, name in which such business is carried on.

6. Principal place of business, profession or vocation, and location and style of each branch.

7. In the case of a firm, name and address of each partner.

8. In the case of partner in a firm, name and address of each firm or firms in which he is a partner.

9. In the case of a salaried person, amount of salary per annum.

10. In the case of a Government employee, Government Department and post held.

11. In the case of a retired Government employee, last post held, Government Department under which such post was held and date of retirement.

12. In the case of a retired employee of a non-Government employer, particulars of last post held.

13. In the case of any other person, particulars of profession or vocation or, as the case may be, former profession or vocation.

14. Particulars of high denomination bank notes tendered.

Denomination Number of Notes Distinctive Numbers* Total value
Rs. 1000
Rs. 5000
Rs. 10000
Rs. Rupees (in words)
*Distinctive numbers of bank notes tendered should be furnished indicating alphabetical and numerical prefixes of the notes. Attach a statement if space is not adequate.

15. Reasons for keeping the amount in cash in notes of such high denominations

16. When and from what source did the bank notes come into possession?

17. If any of the notes tendered represent borrowings, the name(s) and address (es) of the persons from whom borrowed and the dated on which borrowed.

18. Manner in which payment of value of the bank notes is desired; i.e., in cash or payment to bank, etc.

19. If payment is to be made into a bank account, full details of the bank account.

20. Has any other declaration been made in respect of other bank notes of the owner? If so, state full particulars.

21. If the declarant is not the owner of the bank notes, capacity in which declaration is signed.

I, , son/daughter/wife of hereby solemnly declare (name in block letters)(name of father/husband) that the particulars furnished above are full, true and correct to the best of my knowledge and belief.

I further declare that the bank notes tendered herewith belong to me to and are not held benami. name of owner of bank notes not filed any other declaration under this Act.

I also solemnly affirm that I have  filed another/other declaration(s) as per particulars attached.

I further declare that I am making this declaration in my capacity as and that I am competent to make this declaration and verify it, designation, etc.

Place: Date:

(Signature of declarant)

I, hereby testify that I know the declarant and certify that the (name in block letters)

above declaration was signed in my presence. Place:


(Signature and designation)

High Denomination Bank Notes (Demonetisation) Act, 1978 Back

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