To : Mr. T.K.

RAVI From: (Name)

Kalina Office, Mumbai Employee Code No.
Mobile No. 9893287199
Permanent Account No.
Financial Year : 2014-15 Residential Address:
Assessment Year : 2015-16
Sub: Income tax declaration of direct savings for the F/Y 2014 -15
I hereby declare that the following amounts are / would be paid / invested by me during the Financial
Year ending 31st March 2015, which please be taken into account for computing Income-tax payable
by me during the said year.
1. Life Insurance Premium paid in respect of policies taken on own life / on the life of wife / husband
or on life of any minor children as the case may be as detailed below:
S. No. Policy No. Sum Assured Type of Policy Total Amount of Premium
1
2
3
4
5
6
7
8
Total 0.0 0.0
2. National Saving Certificates (VIII Issue) purchased / to be purchased during the period April 2014
to March 2015 (Certificates should be in the name of self) as detailed below:
S. No. Certificate No. Date of Purchase
1
2
3. Subscription to Public Provident Fund Scheme, 1968 as detailed below:
PPF A/c. No. Name of the A/c. Holder
5518002299 Sudhir Gopal
4. Tuition Fees paid / to be paid to School / College for Children (maximum 2 children)
Name of the Children
Name of School /
College / Institution
1
2
5. Unit Link Insurance Premium paid / to be paid to UTI during the period from April 2014 to March 2015
Policy / Membership No. Date of Payment
1
2
6. Accrued interest on NSC:
Certificate No. Date of Purchase
Amount of NSC
(Rs.)
Interest (Rs.)
7. Fixed Deposit for 5 years or more with a Scheduled Bank or any other Tax Saving Investment:
Fixed Deposit Receipt No. Date of Purchase Period Amount (Rs.)
201,2ND FLOOR, KHB COLONY, HOOTAGALLI
HUNSUR MAIN ROAD HOOTAGALLI MYSORE
SY NO 67 KHATA NO 177 178, MYSORE-570018
GOPAL SUDHIR
4312
BTVPS1270H
0.0
Amount (Rs.)
Amount (Rs.)
Amount (Rs.)
1,50,000/-
Total
Total 0.0
Total premium (Rs.)
9. U/S 80CCC - Premium paid / to be paid under Pension Scheme
Name of Company Sum Assured Date of Purchase Total Premium (Rs.)
10. U/S 80D - Mediclaim premium (maximum allowed Rs.15,000/-):
Policy No. Sum Assured
1
11. Interest paid on Housing Loan u/s. 24(1) (Vi) during the period from April 2014 to March 2015
(to consider this amount, provisional statement of the Financial Institution from where housing loan
is taken to be attached):
Name of the Finance Company /
Bank & the date of Loan made
Date of possession of
the said house
ICICI Bank Ltd., A/C no:
LBMYS00002011967
14/08/2013
12. Rent paid - Eligible for exemption u/s 10 (13A):
I am in receipt of monthly House Rent Allowance and residing in a rented house (which is not
owned by me) and I pay monthly rent as per the attached receipts.
Name and address of the
Landlord
Address of the rented
house
Note: Exemption is not available for the house where the employee does not pay any rent. Rent Receipt
13. Perquisite
For Independent Accommodation - Rent paid by Company @ Rs.per month 10,000/-
For Sharing Accommodation - Propo. Rent (Rent / No. of person) paid by Co. @ Rs.00.00 p.m.
I declare that the particulars furnished by me are true and correct to the best of my knowledge and belief.
Name : GOPAL SUDHIR
Employee No.: 4312
Place: WAIDHAN
Date:

has be accompanied by registered Lease Agreement copy & PAN Card copy of the Landlord for claiming tax
exemption.
Signature
Total Premium (Rs.)
Total amount of Principal and Interest paid / to be
paid during the F/Y
Total Rent paid / to be paid for the period April 2014 to
March 2015
Principal----- 33990.70
Interest ----- 240252.50