Employee Name: Permanent Account Number: Grade / Designation:

Employee Code: Location: Joining Date:

I hereby declare the following information for the purpose of computing my tax liability under Sec.192 of the Income Tax Act, 1961 and deduction of tax at source (TDS) thereon for the financial year 2012-13.

A. Deduction Under Section 24 & Section 80 Sl. No. Particulars Deduction Under Section 24 1 Interest on Housing Loan (Please attach Provisional Certificate from Bank) Date of Possession of House Property : Deduction Under Chapter VI A 1 80C Life Insurance Premium (Not exceeding 20% of sum assured for policy issued up to 31.3.12 and not exceeding 10% of sum assured for policy issued after 01.04.12) 2 80C Public Provident Fund (Max. Rs.100,000/-) 3 80C Deposit in NSC 4 80C ULIP of UTI/LIC 5 80C Mutual Funds (Equity Linked Savings Scheme) 6 80C Principal Loan Repayment (Housing Loan) 7 80C Tuition fees for education of children (Only Tuition fees of School / College / University) 8 80C Fixed Deposit with Schedule Bank for 5 years or more 9 80CCC Contribution to Pension Fund 10 80CCG Investment made under a Equity Saving Scheme notified by Central Govt. (Deduction @ 50% is allowed on maximum investment of Rs.50,000/-, Central Govt. yet to frame the scheme) 11 80D Medical Insurance Premium - For Self, Spouse & Children# - For Parents# - Additional amount if policy is taken on the health of senior citizen (60 years or more) # Including payment on a/c of preventive health check up to Rs.5000/12 80DD Medical Treatment of handicapped Dependent who is person with disability (Ordinary disability) - If Severe disability 13 80DDB Medical Treatment (Specified Disease only) - for Senior citizen 14 80E Interest on higher education loan 15 80U Deduction in case of self being totally blind or physically handicapped 16 Any Others (please specify):

Max Limit (Rs.) Rs. 1,50,000/-

Amount (Rs.)

Rs.1,00,000/-

Rs. 25,000/-

Rs. 15,000/Rs. 15,000/Rs. 5,000/-

Rs. 50,000/Rs. 1,00,000/Rs. 40,000/Rs. 60,000/No Limit Rs. 50,000/-

B. Details of Accommodation
I am Staying in : a. Own Accommodation c. Company Leased Accommodation b. Rental Accommodation

d. Company Colony
(Bachelor / Family)

If Rental Accommodation please provide the following details (Please attach Rent Agreement & receipts for rent paid so far) Name & Address of House Owner Address of Accommodation Period of Rent P.M. Agreement (Rs.) PAN of House Owner:

C. For claiming deduction under Income-tax Act for Education Allowance (Rs.100/- pm/child)
Sr.No. 1 2 Name of Son/ Daughter Particulars of Children Standard Name & Address of School/ College Expenses p.a.

D. For claiming deduction under Income-tax Act for Conveyance Allowance (Rs.800/- per month)
I certify that I incur an average expenditure of Rs. ________________p.m. for the purpose of commuting between my residence and the work-place. OR I have been given company car and the same is used only for commuting between my residence and the work place and other official work. OR I am using pick up and drop facility provided by company for commuting between my residence and the work place.

E. In respect of New Employees Only (Employees joined after 01st April, 2012)
Working previously in Current financial year? : YES NO If YES please submit the Form 16 / Form No.12B If NO please sign the declaration below: I hereby declare that with reference to section 192(2) of the Income Tax Act and / or any other section of the said Act and or the rules made there under, I do not have any income under the head Salaries from any other employer and/or I have elected not to furnish you with any details of income under the head Salaries from any other employer either due or received by me during the current financial year 2012-13. ___________________ Signature of Employee

F. Other Income if any

YES NO If YES please submit Form No. 12C Declaration: I hereby declare that all the information given above by me is true and correct. I undertake to notify you immediately of any change in the above facts. Any Income Tax liability arising out of a wrong declaration will be my responsibility, and I undertake to indemnify the Company and its officers from all consequences, monetary and otherwise, arising out of any incorrect and/or incomplete information provided in this declaration. I undertake to produce to the company ON OR BEFORE 15TH FEBRUARY 2013 OR prior to leaving the company, appropriate documentary evidence in respect of payments mentioned above. Failing this, I agree that the company will be free to cancel the exemptions allowed and to recover from me the additional Income-tax arising there from. PLACE : DATE : SIGNATURE :