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

2012

NAME OF COMPANY: LOCATION:

EMPLOYEE CODE NO. PAN:

(As appears on the Pay Slip)

NAME OF EMPLOYEE:
Rs. (No paise)
RENT PAID BY EMPLOYEE ( FOR HRA COMPUTATION PURPOSE ) For
1 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.

2 SEC.80D - MEDICLAIM PREMIUM (Max. Rs.35,000)

3 Sec.80DD Handicapped or Sec.80U Disability

4 SEC. 80CCC - JEEVAN SURAKSHA / OTHER PENSION SCHEMES

5 80E - EDUCATION LOAN INTEREST (Only Interest Component)

6 LOSS UNDER THE HEAD "INCOME FROM HOUSE PROPERTY"

INTEREST PAID IN RESPECT OF SELF-OCCUPIED PROPERTY

7
Interest on Loans taken after 01.04.1999 (Max. Rs.1,50,000)

8 UNITS OF MUTUAL FUND [ Section 10(23D) ]

9 FIXED DEPOSIT WITH SCHEDULE BANK MORE THAN 5 YEARS.

10 LIFE INSURANCE PREMIA (by LIC or any other Insurer) - LIP

11 ULIP / DHANRAKSHA

12 PUBLIC PROVIDENT FUND - PPF (Max. Rs.70,000)

13 HOUSING LOAN REPAYMENT - PRINCIPAL AMOUNT

14 NATIONAL SAVINGS CERTIFICATE VIII SERIES - NSC VIII

15 ACCRUED INTEREST ON NSC VIII

(As per
16 TUITION FEES PAID TO UNIVERSITY, COLLEGE, SCHOOL
Rules)
17 80CCF - New Long Term Infrastructure Bonds (Rs.20,000 Max)

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, 2012, 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.

Signature of Employee: Date:

NAME OF EMPLOYEE: (in block letters)