Accounting /Payroll Process COMPANY NAME: ________________________________ Investment Declaration for Income Tax For the Financial Year

2 !"#!$
Instructions for submitting this form. 1. Employees are requested to read the form carefully before submitting the same. 2. All the fields are compulsory. (please enter Zero if not applicable dont leave any field blan ! ". #ou have to send the proofs of the investment latest by !%th &an'ar( 2 !$. $. %lease eep the submitted copy& for your record ' reference. (ull )ame of Employee (athers , .usbands )ame ((ull! Employee )o /ocation +esidential Address Employees %A) (011 2haracters! %lease attach co)( of PAN CA*D for verification A+ ,I- Investment )ro)osal 'n.er /ection 0 C ,Maxim'm limit is *s+!+ /+No 1 2 " $ 9 : ; = > 11 Partic'lars /ife Insurance %remium %remium %aid for -elf , -pouse, 2hildren %ost 4ffice 5eposits (265! %ublic %rovident (und (%%(! -ubscriptions for -elf , -pouse, 2hildren )ational -avings 2ertificates ()-2! Interest Accrued on )-2 Investment in Infrastructure 7ond 2hildren Educational E<penses (T'ition Fees Onl(*utual (unds (E/--! ?/I% of ?6I 4ther Investments a! b! +a@iv Aandhi Equity -avings -cheme (=122A! (Applicable for those 3hose gross total income is less than +s. 12 lacs! 2opy of Equity -avings -cheme (*a<imum limit +s. 91&111& deduction available 91B of total investments! Amo'nt Pai. ,*s+lacProof *e1'ire. 2atest 3( !%th &an'ar( 2 !$ 2opy of premium receipts no proposal receipts 3ill be accepted 2opy of the %ass 7oo 5eposit +eceipt for %%( Account ,2opy of %%( %ass 7oo (*A8. +s.1&11&111! 2opy of )-2s 2opy of )-2 2ertificate along 3ith calculations 2opy of 7ond, Ac no3ledgement copy of the payment %roof of e<penses incurred 2opy of *utual (und 2opy required *+,*-

C+ 5o'sin6 2oan *e)a(ment 1 2 %rincipal Interest %aid %rovisional 2ertificate from 7an %rovisional 2ertificate from 7an

Mention the .ate of )ossession of the ho'se : #

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D+ 5*A Exem)tion 'n.er /ec +! ,!"A- 7 Ori6inal *ent *ecei)ts for all the months an. if rent is a3ove *s+ %8 )er month8 it sho'l. 3e s'))orte. 9ith the co)( of rent a6reement 9ith the lan.#lor. ,If *ent is a3ove*s+08""":#)m then 2an.#lor.;s PAN Co)( also re1'ire.1 April 211" 2 " $ 9 : ; = > 11 11 12 *ay 211" Cune211" Culy 211" August 211" -eptember 211" 4ctober 211" )ovember 211" 5ecember 211" Canuary 211$ (ebruary 211$ *arch 211$

E+ Cha)ter <IA -ec =1 5 *edical Insurance %remium (2overing self& spouse& children and dependent parents! 2 -ec =1 55 -pecified e<pense on disabled dependent " -ec =1 557 E<p for medical treatment 1 $ 9 -ec =1 ? 5eduction to person 3ith disability -ec =1 E +epayment of loan for higher studies (4nly Interest part 3ill be considered!.

2opy of %remium +eceipt 2ertificate from certified medical practitioner 2ertificate from certified medical practitioner 2ertificate from certified medical practitioner 2ertificate from ban

F+ E +Me.icals 4ills ,Ori6inal 3ills nee.s to 3e s'3mitte.1.E<emption Allo3ed ma<imum up to +s.19&111 =+ 2eave Travel Allo9ance Exem)tion 'n.er /e+! ,%1 E<empt in 2 years out of $ calendar years. 7loc period starts from 11.11.2111 to "1.12.211" ' ne3 7loc starts from 11.11.211$ to "1.12.211;. from his employer for himself and his family& in connection 3ith his proceeding on leave to any place in IndiaD 4riginal tic ets required& in case of travel by air& boarding pass 3ill be required as proof of travel

5eclarationD I EEEEEEEEE& hereby declare that 3hat is stated above is true to the best of my information ' belief. I also certify that payments listed in paraFs A& 7& 2& 5& E& ( ' A have been made by me. I also underta e that any income ta< liability arising out of 3rong declaration 3ill be my responsibility.

Employees -ignature ' 5ate

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Declaration for claimin6 .e.'ctions 'n.er section 2$,3- > 0 C ,2-,xviiof the Income Tax Act8 !?@! I EEEEEEEEEEEEE. I hereby declare that I have ta en a .ome loan from EEEEEEE for a property located at EEEEEEEEEEEEEE. I hereby declare that possession of the above property has been ta en by myself from 5ate EEEEEEEEEEEEE(*onth , #ear!. I also underta e that any income ta< liability arising out of 3rong declaration 3ill be my responsibility. ,If the loan is in the Aoint name )lease s)ecif( the )ortion of loan > interest )ai. 3( (o'+(-ignature! %lace D EEEEEEEEEEEE 5ate D EEEEEEEEEEEE )ote D As per Income ta< Act 1>:1 deduction under section 2$(b!& interest can be availed in the year of actual possession and on3ards till the complete payment of loan. .ouse rent deduction till the date of possession of property only 3ill be allo3ed& if located in the same 2ity. De.'ction ':s+ 0 EE De.'ction in res)ect of interest on ho'sin6 loan sanctione. .'rin6 financial (ear 2 !"#!$ for ac1'irin6 resi.ential ho'se )ro)ert( Additional benefit available up to +s. 111&111 2onditions G o 6his should be the first house of the person o /oan should have been sanctioned bet3een 1 st April 1" and "1st *arch 211$. o /oan sanctioned should not e<ceed +s. 29 lacs o Halue of residential house property should not e<ceed +s. $1 lacs o Individual should not o3n any residential property on the date of sanction of the loan

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2EA<E T*A<E2 A22OBANCE C2AIM FO*M (6o be filled by the employee after the @ourney! Employee )ameD EEEEEEEEEEEEEEEEEEEEEEEE 5ate of CoiningD EEEEEEEEEEEEEEEEEEEEEEEEE I+ &o'rne( Details: -tart date of @ourneyD EEEEEEEEEEEEEEEEEEEE EEEEEEEEEEEEEE End date of @ourneyD

%lace visitedD (romD EEEEEEEEEEEEE toD EEEEEEEEEEEEE *ode of @ourney (Air , 6rain ,+oad! Air , train , 2ar hire charges paidD +s. EEEEEEEEEEEEEEEEEEEE II. /eave availedD (romD EEEEEEEEEEEEEEEEEE toD EEEEEEEEEEEEEEE III. 5ependent members travelled along 9ith self -. )oD 1. 2. ". (%lease attach original tic ets. If the @ourney is by road& please submit original bill. If @ourney is by air please attach boarding passes also! *estriction on Chil.ren 6he e<emption 3ill not be available to more than 2 surviving children of an individual born after 11.11.1>>=. 6his restriction shall not apply in respect of children born before 11.11.1>>= and also in case of multiple births after one child. It may be noted that section 2 (197! of the Act defines a child as includes a step child and an adopted child of the individual Note: Maxim'm allo9a3le exem)tion 9ill 3e e1'al to # )ame +elation Age

1. Ihere the @ourney is performed& by air& an amount not e<ceeding the air economy fare of the national carrier by the shortest route to the place of destination.
2. Ihere places of origin of @ourney and destination are connected by rail and the @ourney is performed by %ublic transport system& an amount not e<ceeding the air0 conditioned first class rail fare , first class fare by the shortest route to the place of destinationJ Employee signatureD EEEEEEEEEEEEE 5ateD EEEEEEEEEEEE

Acco'nts De)artment 1. /6A eligible for ( # EEEEEEEE+s. EEEEEEEEEE 2. /6A payable +s.EEEEEEEEEEEEEE ". Amount of e<emption EEEEEEEEEEEEEE $. Amount ta<able EEEEEEEEEEEEEE

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/i6nat're ,A'thoriCe. Person-

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