TAX DECLARATION FORM FOR INCOME TAX RELIEF - Y.E. 31.03.

2014
NAME OF COMPANY: EMPLOYEE CODE NO.
(As appears on the Pay Slip)

LOCATION: PAN:
(Form without PAN is INVALID)

NAME OF EMPLOYEE:

Rs. (No paise)

RENT PAID BY EMPLOYEE ( FOR HRA COMPUTATION PURPOSE ) For 1 2 3 4 5 6 7 8 9

employees who have joined during the year, the rent amount should only be from date of joining the company till the year end. For Others it should be for the full year.

SEC.80D - MEDICLAIM PREMIUM (Max. Rs.35,000 = 15,000 + 20,000 ) Sec.80DD Handicapped or Sec.80U Disability SEC. 80CCC - JEEVAN SURAKSHA / OTHER PENSION SCHEMES 80E - EDUCATION LOAN INTEREST (Only Interest Component) LOSS UNDER THE HEAD "INCOME FROM HOUSE PROPERTY" INTEREST PAID IN RESPECT OF SELF-OCCUPIED PROPERTY
Interest on Loans taken after 01.04.1999 (Max. Rs.1,50,000)

INTEREST PAID IN RESPECT OF NEW SELF-OCCUPIED PROPERTY (Loan taken after 01.04.2013 & Loan Less than 25 Lakh.) UNITS OF MUTUAL FUND [ Section 10(23D) ]

10 FIXED DEPOSIT WITH SCHEDULE BANK MORE THAN 5 YEARS. 11 LIFE INSURANCE PREMIA (by LIC or any other Insurer) - LIP 12 ULIP / DHANRAKSHA 13 PUBLIC PROVIDENT FUND - PPF (Max. Rs.1,00,000) 14 HOUSING LOAN REPAYMENT - PRINCIPAL AMOUNT 15 NATIONAL SAVINGS CERTIFICATE SERIES - NSC 16 ACCRUED INTEREST ON NSC 17 TUITION FEES PAID TO UNIVERSITY, COLLEGE, SCHOOL 18 INFRASTRUCTURE BONDS (As per old Scheme)
I hereby declare that the information given above is correct and true in all respects and I request the company to allow me the appropriate Income-tax exemption / relief. I undertake to produce to the company, LATEST BY JANUARY 1, 2014, OR prior to leaving the company, appropriate documentary evidence in respect of payments mentioned above. Failing this, I agree that the company wil be free to cancel the exemption allowed and to recover from me the additional Income-tax arising there from.

(As per Rules)

Signature of Employee:
(Form without SIGNATURE is INVALID)

Date:

NAME OF EMPLOYEE: (in block letters)