DECLARATION FORM FOR THE F.Y. 2011-2012
PLEASE NOTE:
» PAN & Address are mandatory. Please do not fail to furnish the same.
» Please indicate details of your investments in appropriate columns only.
(1) Full Name:
Mr. /Mrs./Ms. __________________________________________________________________________
Department ____________________________________ Designation __________________________
Branch _________________________________________________________________________________
Contact No. ____________________________________ Male / Female ______________________
Email Id __ _____________________________________________________________________________
Date of Birth ___________________________________ Date of Joining ______________________
(2) Income Tax Permanent A/c. (PAN) No. : ___________________________________________
(MONDATORY) Please provide Xerox / Scan copy of PAN Card.
Deduction available from salary income under chapter VI A:
|
Sr.
No.
|
Description of
Investment/s
|
Documents Required
|
Maximum
Limit
Rs.
|
Amount in Rs.
(to be filled in by the employee)
|
|
1
|
House Rent paid to the Landlord
|
Original Rent Receipts every month (with Revenue Stamp above Rs.4999/-) or Rent Agreement
|
(Monthly Rent Amount)
|
|
|
2
|
Mediclaim – 80 D
|
Mediclaim Policy Copy or Premium Certificate
|
15,000/-
|
|
|
3
|
Mediclaim – 80 D
(Parents)
|
Mediclaim Policy Copy or Premium Certificate
|
20,000/-
|
|
|
4
|
Interest on Housing Loan Loan taken prior to 01/04/99
|
Certificate from Bank / Financial Institution
|
30,000/-
|
|
|
5
|
Interest on Housing Loan Loan taken after 01/04/99
|
Certificate from Bank / Financial Institution
|
1,50,000/-
|
|
|
6
|
Expenditure on Dependant with – Disability Rs. 50,000 – Several Disability Rs. 1,00,000-80-U
|
Certificate from Prescribed Authority in Form No. 10-IA Sec. 80 DD
|
1,00,000/-
|
|
|
7
|
Expenditure on Specified Disease
|
Certificate from Prescribed Authority in Form No. 10-I Sec. 80 DDB
|
40,000/-
|
Deduction u/s 80 C (Maximum of Rs. 1,00,000/-)
|
Sr.
No.
|
Description of
Investment
|
Documents Required
|
Maximum
Limit
Rs.
|
Amount in Rs.
(to be filled in by the employee)
|
|
1
|
Public Provident Fund
|
Copy of Payment Receipt / Passbook
|
70,000/-
|
(Do not write EPF)
|
|
2
|
Life Insurance Premium including Pension Plan & ULIP
|
Copy of Premium Payment Receipt (proposal receipt will not be considered)
|
||
|
3
|
Repayment of Housing Loan Principal
|
Certificate from Bank / Financial Institution
|
||
|
4
|
Mutual Fund (Equity)
(Sec. 10(23D)) |
Statement of Holding
|
||
|
5
|
NSC Purchased during the year
|
Copy of NSC Certificate/s
|
||
|
6
|
Interest on NSC Purchased
|
Statement regarding date of purchase & amount
|
||
|
7
|
Tuition Fees
(Up to Two Children)
|
Copy of Payment Receipt from School
|
||
|
8
|
National Saving Scheme
|
Copy of NSS Certificate/s
|
||
|
9
|
Bank Fixed Deposit (More than 5 Years)
|
Copy of FD Receipt
|
||
|
10
|
Infrastructure Bond
|
Statement of Holding
|
(In addition to Rs. 1,00,000) 20000/-
|
|
|
11
|
Donation to Registered Trust – 80 G
|
Original Donation Receipts & PAN of Donnie
|
||
|
12
|
Other Investments
Medical Bill Reimbursement
|
Original Medical Bills (including Parents, Wife/Husband, Children)
|
1250/- every month
|
DECLARATION
I, declare that the above statement is true to the best of my knowledge and belief. In the event of any change that may occur during the year pertaining to the information given in the form, I undertake to inform the same to the company. Income Tax liability arising due to failure, if any, for not making / not intimating payment / investment made or proposed to be made by me and / or any wrong declaration would be my responsibility.
I further undertake to provide all documentary proofs of payment made by me before 15th March 2012 and if I fail to do so, the company can make full deduction of income tax dues from March 2012 salary.
Date : ___________________________ _________________________________
Signature of the Employee
DECLARATION FOR HOUSE RENT ALLOWANCE RELIEF – FINANCIAL YEAR 2011-12
Details of rent actually paid:
a. Address of residential property in respect of which rent paid.
________________________________________________________________________
__________________________________________________________________________
b. Name of Landlord to whom rent is paid: ________________________________
c. Rent payable / paid during the Financial Year: Rs.____________________
(Please attach copy of Lease / Rent Agreement. In case no agreement is executed submit copy of ORIGINAL rent receipts. In case rent receipt is not submitted, the relief will not be given.)
DECLARATION:
i. I hereby declare that I shall inform immediately to the company any change in monthly rent stated above or discontinuation of house rent payments.
ii. I also declare that no residential accommodations owned by me or by my spouse or by my child or by HUF of which I am a member at the place where I reside or perform the duties of employment.
iii. I hereby declare that what is stated above is true and correct. Any Income Tax dues arising out of wrong declaration will be my sole responsibility.
Date : ______________________________ _________________________________
Signature of Employee