HR DEPARTMENT CONFIDENTIAL

Financial Year 2017-18 Assessment Year 2018-19

We are sending herewith DECLARATION FORMS IN DUPLICATE and request you to

please let us have the following information for the purpose of calculating the
tax liability on your income from SALARIES for the financial year ending
31st March 2018

NAME Mr/Ms. DEPARTMEN

T

I.TAX P.A./GIR No EMPLOYEE

CODE No

I SUM PAID / PAYABLE FOR THE YEAR ENDING ESTIMATED ACTUAL

31.03.2018 OUT OF MY INCOME CHARGEABLE TO TAX RS RS
:-
AND NOT OUT OF ANY BORROWINGS
DEDUCTIONS U/S. 80C / 80CCC /80CCD :-
1 a Towards Insurance Premium for own
life or spouse/your minor child as
the case may be (LIC premium as
applicable i.e.
-Premium amount is eligible to consider for 20% of the
sum assured for policies issued on or before 31.03.2012
-Premium amount is eligible to consider for 10% of the
sum assured for policies issued on or after 01.04.2012
(And others as applicable as per section)
i. Directly
ii. Salary Saving Scheme ( SSS )
b Towards payment for deferred
annuity plans for Insurance for own
life or spouse/your minor child /
married daughter as the case may be.
c Contributions to any recognized
Provident Fund
d Public Provident Fund ( PPF )- for
self or for spouse or any child of such
individual
e Contributions to any approved
superannuation fund
f Savings certificates like NSC etc.
 g ULIP of UTI
h ULIP of LIC MF or other MF as
approved for deduction
i Payment notified annuity LIC plan
like New Jeevan Dhara,New Jeevan
dhara -I or New Jeevan Akshay
etc.approved plan
j Contribution to notified Pension
fund set up by the UTI / MF
( Retirement Benefit Plan )
k Accrued Interest on NSC Issue VIII
during the year for investment made
in previous year
l Deposit in notified Home Loan
Account or contributions to notified
pension fund set up by the National
Housing Bank
m Tuition fees paid up to any two
children's to any University, School,
college or educational institutions
n Deposit in Senior Citizen Scheme
-2004 for Sr.Citizens
o Investment in 5 year term deposit
with Post office.
p Repayment of loan for principal
amount paid for housing purpose
( specify nature of loan )
Interest on borrowed capital in
respect of self occupied house
property - Deduction allowed under
house property as per terms and
conditions u/s.24

q Deposit in notified term deposit of

Banks for 5 years

2 U/S. 80CCC
Contribution to Pension Fund

3 U/S. 80 CCD
Contribution to Pension scheme of
Central Government
 4 U/S. 80 D
As sum paid under MEDICLAIM
Scheme up to Rs. 15,000/- p.a. for
Sr.citizen parents

II DESCRIBE THE TYPE OF

ACCOMMODATION YOU HAVE -
WHETHER OWNED BY YOU OR TAKEN
ON RENT . { If rented, name of city
and amount of rent per month
( Rent Receipt is essential ) No
Deduction shall be granted without
proof of Rent Receipts

III CHILDREN EDUCATION ALLOWANCE

u.s 10 (14)(ii) [ Maximum 2 children ]
Name of the Child/Children
1
2
Total amount claimed @ Rs.50/- per
month per child

IV TRANSPORT ALLOWANCE -
u/s. 10(14)(I)
Declaration of Transport Allowance
( As per enclosed format A & B )

I declare that what is stated above is correct.

Date :- Signature :-

Residential Address as per PAN details

( Office address will not be accepted )

Note :-
1. The above information should be submitted before 30.04.2017

a. Please note that if the declaration is not received by us on or before the due date
i.e. 30.04.2017 or immediately on date of joining for new employees appointed
during the year, then it will not be possible for the Company to give deduction in
respect of payment towards LIC,PPF,NSC,ELSS etc made directly by the employee.
 b. If any false declaration is given, employee shall be liable to pay the tax directly to
the Income tax Authorities along with the penal interest thereon and Company shall
not be answerable/responsible for the same.

2. Please submit one copy of the Declaration with the estimated figures of the investments
tobe made by you on/by 30.04.17. For the said Declaration you should submit the proofs of
Investments immediately on Investment made and mostly by February,2018 end. If Income-
Tax Department calls for any original document, it will be your responsibility to produce
the same in future.

3. Please note that submission of the above mentioned Declaration is Compulsory for all the
employees. Deduction permissible under the head SALARIES shall be accepted in writing
as mentioned above and STRICTLY, NO VERBAL DECLARATION WILL BE ACCEPTED.

4. IN CASE OF EMPLOYEE IS LIVING IN BETWEEN THE DECLARATION IS NOT APPLICABLE FOR

FULL AND FINAL SETTLEMENT BUT AT THAT TIME DEDUCTION WILL BE AT ACTUAL AND IF ANY
AMOUNT IS REQUIRED TO BE REIMBURSED TOWARDS THE TAX AND INTEREST THE SAME WILL BE
REIMBURSED FROM THE DECLARING EMPLOYEE.
Declaration A ( tobe given by the employee in the beginning of the year )

Name :- Mr/Ms.

Residential Address :-

Date :-

To :-

Ref :- Declaration in respect of Transport Allowance.

This is to confirm that TRANSPORT ALLOWANCE of Rs.1600/- p.m. being

granted to me by the company is expected to be fully spent for the purpose
of commuting between the place of duty and my residence. Hence I
request you to exempt this amount from my income.

Signature
 Declaration B ( to be given by the employee at the end of the year )

Name :- Mr/Ms.

Residential Address :-

Date :-

To :-

Ref :- Declaration in respect of Transport Allowance.

I hereby confirm that I have spent more than Rs. 19,200/- ( Rs. Nineteen
thousand two Hundred Only ) for commuting between my office at
_____________and my residence at ( residential
address .........................................................................
................................................................................................................................
.....
during the period 01.04.2017 to 31.03.2018

Signature