MIRAFRA SOFTWARE TECHNOLOGIES PVT LTD

INVESTMENT DECLARATION FORM FOR THE YEAR 2016-2017

EMPLOYEE NAME

GENDER EMP ID
LOCATION PAN NO.

DATE OF BIRTH DATE OF JOINING

PRESENT RESIDENTIAL
LINE 1
ADDRESS OF THE
EMPLOYEE (SHOULD BE LINE 2
SAME AS PER RENT
RECEIPT OR AS PER LINE 3
HOUSING LOAN
CERTIFICATE)
CITY WITH PIN CODE
IF THE ABOVE MENTIONED PROPERTY IS TAKEN ON RENT/LEASE PLEASE ENTER THE DETAILS BELOW
Month Amount(Rs.) Remarks
Apr-16 1. Please enter your monthly rent as per rent receipts
May-16 2. Further if the rent paid per year is more than Rs. 100,000/-,
Jun-16 the employee has to submit the PAN card of the
Jul-16 landlord/house owner and mention the same below.
Aug-16 3. In case, if the landlord doesnt have a PAN, he/she must
Sep-16 sign the self-declaration(format enclosed) saying that he/she
Oct-16 doesnt have the PAN card
Nov-16 4. If the above requirement is not been met, then HRA
Dec-16 exemption will not be considered for the purpose of tax
Jan-17 deduction by the employer
Feb-17
Landlord's Name:
Mar-17
TOTAL - Landlord's PAN :
EXEMPTION UNDER SECTION 24 OF THE INCOME TAX ACT, 1961 - HOUSING LOAN
Property 1 Property 2

LINE 1

ADDRESS OF THE
PROPERTY LINE 2

CITY WITH PIN CODE

Status of the property (Self occupied / Let out)

Housing loan taken from

Aforesaid housing loan amount

Date on which loan taken

Purpose of loan(Construction/Purchase/Repairs)

Date on which Constrution is / will be completed

Date of possession of the property
Value of the Residential House Property
OWNERSHIP ( JOINT OR SOLE)

If, JOINT OWNERSHIP, Name of the Joint Owner's

Relationship with Joint Owner's

Share of JoInt Owner's in the property

Amount of Interest on housing loan (Fin. Year 2015-16)

Amount of interest for pre-construction period

If Let Out, Rent received per month
Month from which the above rent is received

Please provide separate annexure if more than two property

 DECLARATION FOR DEDUCTION OF INCOME TAX AT SOURCE FROM SALARIES UNDER SECTION 192 OF THE INCOME TAX ACT, 1962.

S No Particulars of Invesment Section Amount(Rs.)

Deduction under section 80C and 80CCC
1 Life Insurance Premium (For Self, Spouse & Children) MUST ENTER POLICY DETAILS 80 C
Policy No Policy Holder Relationship Sum Assured Mode(M/Q/H/Y) Total Amount Paid

Insurance Premium restricted to maximum of 20% of the sum Assured on Polices issued on or after 01.04.2003

Insurance Premium restricted to maximum of 10% of the sum Assured on Polices issued on or after 01.04.2012

2 Deposit in Public Provident Fund (For Self, Spouse & Children) 80 C

3 Amount deposited under Unit Linked Insurance Plan(ULIP) 80 C
4 Amount deposited under National Savings Certificate (NSC) (For Self Only) 80 C
5 Interest on National Savings Certificate (For Self Only) 80 C
6 Registration Charges incurred for purchase of property - First year only 80 C
7 Housing Loan Principal Repayment 80 C
8 Tuition Fees paid - First Child 80 C
9 Tuition Fees paid - Second Child 80 C
10 5 Years Tax Saving Fixed Deposit 80 C
11 Tax Saver Mutual Funds (For Self Only) 80 C
12 Post Office Term Deposit for 5 years or more eligible under the Income Tax Rules 80 C
13 Others 80 C
14 Pension Fund Contribution (For Self Only) 80 CCC
Total Deductions Under Section 80 C & 80 CCC (Maximum of Rs. 1.5 lac) -
Other Deductions
Self 80 D
Medical Insurance Premium paid by Cheque
1 Parents Select list 80 D
Preventive health check-up for self, spouse, dependent children or parents 80 D
2 Medical Treatment of Dependent suffering from Permanent Disability 80 DD
3 Expenditure on Medical Treatment for Specified disease 80 DDB
4 Repayment of Interest against Higher Educational Loan 80 E
During which year the interest was first paid (Mandatory) (Mention Month & Year) Month & Year
5 Permanent Physical Disability 80 U
6 Rajiv Gandhi Equity Savings Scheme 80 CCG

PARTICULARS OF PREVIOUS EMPLOYER JOINED ON OR AFTER 01-APRIL-2016

S No Particulars of Invesment Amount(Rs.)
1 Income after Exemptions
2 Deductions under Chapter VIA including PF considered by the previous employer in Form 16
3 Professional Tax (PT)
4 Tax Deducted at Source (TDS)
Form 16 or Tax Computation from previous employer and Form 12 B should be furnished

I undertake to make the above said investments qualifying under the provisions of the Income Tax Act, 1961 during the financial year 2016-17 and submit the invesment proof thereof
alongwith rent receipts(if applicable) by 10-Jan-2017

I do hereby declare that what is stated above is true and correct, the proposed investment mentioned above will be completed on or before declared dates for final computation of
Income Tax for the financial year 2016-17. I also authorise the Company to recover tax (TDS) from my salary.

I am personally liable to Income Tax Proceedings for any misstatements in the declaration of proofs submitted herewith if they are inconsistent with the requirement of Income Tax Act,
1961. Further, in case of any change in above declaration, I would revise it and inform immediately.

Date : Signature of the Employee

 FORM No. 12C
[See rule 26 B]
Form for sending particulars of income under section 192 (2B) for the year ending 31-Mar-2017

1. Name and address of the employee :

2. Permanent Account Number :

3. Residential status :

4. Particulars of income under any head of income other than "salaries" (not being a loss
under any such head other than the loss under the head "Income from house property")
received in the financial year.
Rs.
(i) Income from house property 0
(in case of loss, enclose computation thereof)

(ii) Profits and gains of business or profession 0

(iii) Capital Gains

0
(iv) Income from other sources
(a) Dividends Rs. 0
(b) Interest Rs. 0
(c) Other Income (specify) Rs. 0

Total Rs. 0

5. Aggregate of sub-items (i) to (iv) of item 4. Total Rs. 0

6. Tax deducted at source [enclose certificate(s) issued Rs. 0

under section 203]

Place :
Date :
Signature of the employee

Verfication
I do hereby declare that what is stated above is true to the best of my knowledge and belief.

Verified today, the ________ day of ____________ Month __________ Year

Place :

Date :
Signature of the employee
 Annexure to Form No.12 C
Computation of Income From House Property
Name of the Employee SHARMESH KUMAR
G31, VijayaSri Elixir,
House property's Location : Sy.No. 56/3, Nellurahalli,
Borewell Road, Whitefiled
Bangalore- 560066
Option A - Self Occupied Property

I declare that this is the only property owned by me and that no benefit has been derived by me
from it during the year April 2016 to March 2017

I further declare that I have taken a loan from -------------------and that the total interest for the year
1st April 2016 to 31st March 2017 on such a loan / loans amounts to Rs.---------- p.a. . I further
declare that an amount of Rs.Nil has been received by me as interest susidy from the company.

Computation of Income from House

Property:
Actual Interest Paid / Payable during the year Rs.
Less: Interest subsidy given by the Company Rs.
Interest Under Section 24(i) Rs. 0
Restricted to Rs. 2,00,000 where the property has been constructed or
purchased with borrowed capital on or after 01.04.1999. In all other
circumstaces, restricted to Rs. 30,000.
Income From House Property Rs. 0

AND/OR
Option B - Loss on House Property(Other than Self-occupied)
I have more than one property / income has been derived from my property / properties during the
year 1st April 2016 to 31st March 2017, computation of which is as follows.

Notional Rent / Actual Rent Rs. 0

Less: Taxes levied by local authorities borne
by owner when property is occupied by a 0
tenant, on actual paymentof the tax Rs.
Annual Value Rs. 0

Less:
Standard Deduction 30% Rs. 0
Interest on borrowed capital Rs. 0
Interest subsidy received from the company Rs.
Income From House Property Rs. 0
(Restricted to Rs. NIL for properties let out during part of the year)

Date: (Signature of the employee)

 Category Documents Required
Life Insurance Premium Premium paid certificate issued by
the insurance company
Checking Tips / Guidelines
1. The document submitted
should be a premium paid
receipt/certificate. It should not be
any other document like policy
details or payment notice etc.
Benefit under Income Tax
1. The benefit is available for
any insurance premium paid for
insurance on the life of self,
spouse or children

or 2. The receipt date must fall 2. The premium must be paid by

in current financial year i.e. the employee
between 1st April 2016 and 31st
March 2017.

Receipt issued by the insurance 3. Receipt should be in the 3. Benefit is available for actual
company. name of employee or he should premium paid or 20% of sum
be proposer. assured whichever is lower.

4. In case the receipt is in the 4. In respect of premium paid on

name of the spouse/children, self life insurance policy issued on or
declaration must be submitted after 1-Apr-2016, the benefit of
deduction is restricted to 10 % of
the sum assured.

5. No benefit is available for 5. Part of overall limit of Rs

late payment charges. 1,50,000 under Section 80 C

Public Provident Fund 1. Copy of Pass Book for the 1. The receipt date must fall in 1. Part of overall limit of Rs
payment in current financial year current financial year i.e. between 1,50,000 under Section 80 C.
1st April 2016 and 31st March
2017

2. The receipt/account can be

or in the name of self, spouse or
children
2. Deposit receipt acknowledged 3. In case the receipt/account
by the bank If paid in cash is not in employees name, self-
declaration form should be
submitted.

4. Interest part is not available

for exemption.

National Savings Certificate
Copy of NSC 1. NSC should have been 1. Part of overall limit of Rs
issued in current financial year 1,50,000 under Section 80 C.
i.e. (April16- March17).
2. NSC must be in the name
of employee and not in any other
name.
3. Any interest or bonus
accrued on NSC is not available
for exemption.

ULIP 1. Premium paid certificate issued 1. The document submitted
by the insurance company should be a premium paid
receipt/certificate. It should not be
a policy details or payment
notice.
1 The benefit is available for
any insurance premium paid for
insurance on the life of self,
spouse or children

2. The receipt date must fall in 2 The premium must be paid

current financial year i.e. between by the employee
or 1st April 2016 and 31st March
2017.

2. Receipt issued by the insurance 3. Receipt should be in the 3 Benefit is available for
company. name of employee or he should actual premium paid or 20% of
be proposer. sum assured whichever is lower.

4. In case the receipt is in the 4. In respect of premium paid on

name of the spouse/children, self life insurance policy issued on or
declaration must be submitted after 1-Apr-2016, the benefit of
deduction is restricted to 10 % of
the sum assured.

5. No benefit is available for 5 Part of overall limit of Rs

late payment charges. 1,50,000 under Section 80 C
Mutual Funds 1. Statement of account issued by 1. Benefit is available for 1. Benefit is available for
the mutual fund. investment in tax saver funds investment in tax saver funds only.
only and not in any other mutual
fund. ALL Tax Saver Funds will
have the word TAX in their
names with only exception of
HDFC long term advantage Fund
which is a tax saver fund but
does not have TAX in its name.

2. The receipt date must fall in 2. Part of overall limit of

current financial year i.e. between Rs1,50,000 under Section 80 C
or 1st April 2016 and 31st
March2017.

2. Acknowledged copy of 3. The mutual fund must be in

application form If Supported by the name of the employee.
bank statement

Tuition fees 1. Receipt issued by 1. The receipt date must fall 1. Benefit is for full time
school/college/university/ educational in current financial year i.e. education of two children of the
institution between 1st April 2016 and 31st employee
March 2017

OR 2. Benefit is available for 2. Part of overall limit of

tuition fees only and not for any Rs1,50,000 under Section 80 C
other items like annual charges,
bus charges, development
charges, building fund, late fees
etc.

2. Certificate issued by school 3. Benefit is available for

/college/university/ educational maximum two children of
institution for payment of tuition fees employee.
during the financial year

4. Benefit is available for full

time education.

Bank deposit Fixed deposit receipt issued by the 1. The date of issue of FD 1. Benefit is available for fixed
bank must fall in current financial year deposit of five years period or
i.e. between 1 April 2016 and more
st

31st March 2017

2. Fixed Deposit Receipt 2. Part of overall limit of

must be in the name of Rs1,50,000 under Section 80 C
employee and not in any other
name.
3. Fixed deposit should be
for period of 5 year or more. It
should be clearly mentioned on
the fixed deposit receipt that
the benefit under section 80 C
is available for the same
 Category Documents Required
Section 80D Receipt/Certificate for payment of
Medical Insurance premium and it should contain
specifically that the amount paid is
eligible under the said section.
Checking Tips / Guidelines
1. The receipt date must fall in
current financial year i.e.
between 1st April 2016 and 31st
March 2017.
Benefit under Income Tax
1. Benefit up to Rs 25000 p.a.
for insurance policy for self,
spouse and dependent children,
Rs.30000 if a senior citizen is
covered.

2. Receipt should be in the 2. Additional benefit for Rs

name of employee. 25000 is available for the payment
of medical insurance premium for
parents whether dependent on
him or not, Rs. 30000 if any
parent is senior citizen.

3. Deduction is available for A deduction of Rs 5,000 is

self, spouse, dependent children allowed for preventive health
and dependent parents only check-up for self, spouse,
dependent children or parents.
The above deduction to be within
the overall limit of
Rs.15,000/Rs.20,000

Section 80DD 1. Self declaration that the person 1. The receipt date for medical 1. Rs 50,000 benefit
Medical treatment of dependent with is dependent on employee treatment or payment to LIC/UTI (> 40 %< 80 %disability),
physical disability falls in current financial year i.e. Rs1,00,000(>=80 % disability).
between 1st April 2016 and 31st
March 2017.

2. Certificate issued for 2. The benefit is available for

physical handicap should be valid any expenditure (greater than
till 31st March17. or equal to Rs. 1) on medical
And treatment, whether the total
medical expenditure is equal to
Rs.50000/100000 or not.

2. Any support for medical 3. Dependent means spouse, 3. Dependent means spouse,
treatment of dependent for any children, parents, brother or children, parents, brother or sister.
amount or receipt for the amount sister
paid to LIC/UTI for the policy
4. Certificate (Rule 11 A) to be
issued by competent medical
And authority in the prescribed form
(Form 10-IA) and manner.

3. Copy of certificate issued by

medical authority in the prescribed
form and manner

Section 80DDB
Expenditure on treatment of specific
diseases for self or dependants
1. In case deduction is claimed for
any dependant, Self declaration that
the person is dependent on
employee
1. The receipt for medical
treatment date must fall in
current financial year i.e.
between 1st April 2016 and 31st
March 2017
1. Deduction is allowed for the
amount actually paid or Rs.40000
(Rs60000 in case of senior
citizen) which ever is less.

and 2. Certificate issued for 2. Deduction is available for

medical treatment should be self, spouse, children, parents,
valid till 31 March17
st
brother and sister.
2. Bills for medical treatment of 3. Dependent means spouse, 3. Deduction shall be reduced
self or dependant as the case may children, parents, brother or by the amount received, if any
be .and sister under an insurance policy or
reimbursed by an employer.

3. Details of amount received, if 4. Certificate to be issued by

any , under an insurance from neurologist, oncologist urologist
insurance company or reimbursed by hematologist or any other
employer for medical treatment of specialist as prescribed in rule
employee/dependent. 11DD working in Government
hospital in the prescribed form
(Form 10-I) and manner.
 4. Copy of certificate issued by 5. For the purposes of Section
medical authority in the prescribed 80DDB, the following shall be the
form and manner. eligible diseases or ailments

i. Neurological Diseases where

the disability level has been
certified to be of 40% and above,

ii. Malignant Cancers

iii. Full Blown Acquired Immuno-
Deficiency Syndrome (AIDS) ;

iv. Chronic Renal failure

v. Hemophilia
vi. Thalassaemia

Section 80 E
Interest paid on Education Loan
1 Letter / certificate from the Bank / 1. Loan should have been 1. Interest paid on education
Financial Institution specifying the taken by employee. loan taken by employee from any
following: financial institution or approved
chartable institution for the
purpose of pursuing higher
education by self, spouse,
children or relatives

Said loan is an Educational loan. 2. Said loan is an Educational 2. Deduction is allowed for the
loan for pursuing higher Interest paid in the initial
education by self, spouse or assessment year and seven
children. assessment years immediately
succeeding the initial assessment
year.

Amount of interest paid on the loan 3. Benefit is available for
in the current year (Apr16Mar17) interest paid on the loan in the
current year (Apr16Mar17). If
there is no payment against
interest, no benefit shall be
available under this section
3. Initial assessment year
means the assessment year
relevant to the previous year in
which the assessee starts paying
the interest on the loan.

First year in which interest payment 4. Higher education means full

was made. time studies pursued after
passing Senior Secondary
Examination or its equivalent from
any school, board, university
recognised by the Central
Government or State Government
or Local Authority

5. Financial institution means a

banking company to which the
banking regulation act applies and
any other financial institution
approved by central government

6. Approved chartable
institution means an institution
established for charitable purpose
and approved by prescribed
authority

7. No Limit

Section 80 U
Person with self disability
1. Copy of certificate issued by 1. Certificate issued for 1. Rs 50,000 benefit (< 80
medical authority in the prescribed medical treatment should be %disability),Rs1,00,000(>=80 %
form and manner valid till 31st March16 disability)
2. Disability or Severe Disability
within the meaning of the Section
2 of the Persons with Disabilities
(Equal Opportunities, Protection
of Rights and Full Participation)
Act, 1995
3. Certificate (Rule 11 A) to be
issued by competent medical
authority in the prescribed form
(Form 10-IA) and manner.
 DECLARATION REGARDING PERMANENT ACCOUNT NUMBER

I, ................................................(name of the landlord), residing at

s/o do hereby confirm that I have given my property on rent
(details of property given on rent) to Mr
at. on monthly rent of Rs effective from

I, further confirm that I do not hold any Permanent account Number (PAN) issued by the tax authorities

The above information is true and correct to the best of my knowledge and I shall be personally res
liable if the same is found to be incorrect. Further I shall immediately furnish the PAN if obtained by m
to the signing of this declaration.

Place :
Date :
Nature and ID proof of Landlord :
Signature b
Note :
If the landlord does not have PAN, he/she has to mention any other valid ID proof like Passport, Driving
Ration Card or Voter's ID along with a copy of the same should be attached with this declaration
 TO WHOMSOEVER IT MAY CONCERN

I,__________________________ (name of joint owner), being joint owner to the extent of ___ %
_______________________________________________________ (address of the property), do h
that I am not paying EMI on housing loan taken against aforesaid property. I am not claiming any d
account of interest or principal repayment under any provisions of the Income Tax Act, 1961.

Place :

Date :

Name & Signature of

I ___________________________( name of the employee) do hereby declare that the above mention
is true and corrent and request you to give me the deduction for the entire amount of interest and princ
to the limit prescribed under the Income Tax Act, 1961). Further, I also undertake to pay the amount o
interest and penalty as may be levied by the tax authorities, in case if a different view is taken by th
with respect to the deduction granted to me on account of Income from House Property for any yea
have claimed such deduction.

Place :

Date :

Name & Signature of th