SHRIRAM PISTONS & RINGS LTD.

, GHAZIABAD WORKS
DECLARATION OF DIRECT SAVINGS OTHER THAN THROUGH SALARY FOR F.Y. 2012-13 (ASSESSMENT YEAR 2013-2014)
1. Employee Name 2. Designation 3. Residential Address 4. PAN NO. (own) 4. PAN NO. (Landlord)* : : : : : KAPIL KUMAR OSD C-175, Sangam Vihar, New Delhi CAOPK9202Q Code Section City : : : R&D Delhi 10993

Extn/Cell : 9560558330 No. *Mandatory if Rent paid during the year exeeds Rs. 1,80,000/-

5. Particulars regarding annual payments to be made directly, (Deductions through salary need not to specify). INVESTMENT DETAILS U/S 80C, 80CCC Proofs to be deposited on Quarterly basis a b c d e f g h i j k l Life Insurance Premium NSC -VIII Issue ULIP Equity Linked Plan (ELSS) PPF Interest accrued on NSCs Purchased Repayment of housing loan (Principal portion only) Education Expenses Tution fee only for max. of 2 children Pension Fund (U/S 80 CCC) Bank Fixed Deposit ( Tax Saving- 5 Year Term) Post Office Term Deposit ( Tax Saving- 5Year Term) Any other item (Attach Documents as per Income Tax Act) Total (Maximum Investment Limit - Rs. 1,00,000/-) 25000 25,000.00 25000 25,000.00 Q1 Proprosal Q2 Proprosal Q3 Proprosal Q4 Proposal Total

Other Income Tax benefits over & above Rs. 1,00,000/6) Equity Share Market Investment (u/s 80CCG) (Maximum Investment upto 50,000/- & Tax benefits 50% on this Investment) 7) Medical insurance (Mediclaim) U/S 80 D 8) Repayment of housing loan (Interest portion only) (Maximum Interest Benefit upto Rs. 1,50,000/-) 9) Any other income 10) House Rent paid / payable per month (Attach rent receipts till latest month) Apr. 7000 May 7000 June 7000 July 7000 Aug. 7000 Sep. 7500 Oct. 7500 Nov. 6000 Dec. 6000 Jan. 6000 Feb. 6000 Mar. 6000 Total 80000

11) Leave Travel Assistance (Please tick the appropriate box)

Availed in this F.Y.

Not Availed in this F.Y.

I am aware of the taxability of LTA for the a.y. 2013-2014, I know the provisions of the Income Tax Act, 1961. My LTA for the f.y. 2012-2013 may be taken as (please tick if availed):Taxable Exempt

I declare that the informations furnished above are true and correct to the best of my knowledge and belief. I further declare that above investments have been made out of income tax chargeable to tax. Any change in the information will be intimated immediately. I further declare that Income Tax Benefit of above mentioned Investments have not been taken by my spouse / children.

Place : Date :

Ghaziabad 1/20/2013 Signature of Employee

Details of Investments declared at Page-1 (use additional sheet if more space is required), other than through salary for f.y. 2012-2013 (a) LIC premium (other than u/s 80CCC) paid during the F.Y. 2012-2013 (please do no furnish details of premium paid through salary). Premium Amount Due Date of Actual Date of Policy Nos. S. No Deposit Deposit (Excluding Late Fees)

TOTAL: b) Details of NSCs purchased during F.Y. 2012-2013 S. No NSC No. Date Amount (Rs.)

TOTAL: c) Particulars of ULIP:Membership No. Date of Membership Date of payment Amount (Rs.)

d) Equtiy Linked Saving Scheme of a mutual fund (ELSS):Name of Mutual Fund Folio No. Date Amount (Rs.)

e) Particulars regarding PPF:Account No. Bank & Branch Date of payment Amount (Rs.)

TOTAL: f) Interest Accrued on NSCs VIII Series:NSC No. Date of Purchase Financial Year Amount Interest Amount (Rs.)
th

g) Particulars of Housing Loan Repayment:Financed By Date of payment Principal Interest Amount (Rs.)

h) Education Expenses paid during f.y. 2012-2013, Child 1 2 Total Premium paid U/S 80CCC during the F.Y. 2012-2013, other than mentioned at Above (a) S. No Policy Nos. Date of Preminum paid Premium Amount (Excluding Late Fees) Name of Institutuion Bill No. Bill Date Amount

j)

k) Particulars regarding Medical Insurance Premium (Mediclaim) including Expenditure on Medical Check-up (upto Rs5000/-):Premium Paid Name of Institutuion Policy No. Period for Policy

Signature of Employee