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Exemptions under Section 10 & 17 Employee's Declaration Value of Proof / Bills Produced
Total 27,000.00 -
Other Income
Total - -
I _______________________________________________ do hereby declare that what is stated above is true to the best of my
knowledge and belief.
Date: Signature:
Employee's Income Tax Declaration Form for the Financial Year 2016-17
Name PAN No
Designation Gender
Department DOB
DOJ Email
Work Permit No. Contact No.
S. No. DESCRIPTION
Amount (Rs.)
A Particulars of Income from sources other than salary (optional)
1 Dividends
2 Interest
3 Other Incomes (specify)
Total Earnings -
B Income/(Loss) from House Property
C HRA: Rent Paid/Payable ( Please mention the starting and ending period) Monthly Rent
I, do hereby declare that investment(s) proposed will be completed on or before the proposed date and proof of investme
submitted by 05th January, 2017. Further, incase of any change in above declaration, I would revise it and inform
immediately. I shall indemnify the company for all cost and consequences if any information is found to be incorrect.
Male
Proposed Investment
Date
Metro
† With effect from 1-4-1991, section 80C has been replaced by section 88.
Verification
I,______________________________________________________ do hereby declare that what is stated above is true to the best of my knowledge and belief.
Verified today, the_____________________day of______________________
Place
ANNEXURE
[See column 8 of Form No. 12B]
Particulars of value of perquisites and amount of accretion to employee's provident fund account
Name and address of the employee
Permanent Account No.
Period : Year ending 31st March,_______________
Value of rent-free accommodation or value of any concession in rent for the accommodation provided by the employer (give basis of computation)[See rules
Where accommodation is furnished
Name of
TAN/PAN of
the Where Value as if Cost of furniture (including television sets, radio sets, refrigerators, Perquisite value of furniture (10%
the employer
employee accommodation accommodation other household appliances and air-conditioning of column 5) OR actual hire
is unfurnished is unfurnished plant or equipment) OR hire charges, if hired from a third party charges payable
1 2 3 4 5 6
ANNEXURE
(Contd.)
1 10 11 12 13
Name of Employee
Place
Signature
Total amount
Amount deducted in
of tax
respect of life
deducted
insurance premium,
during the
provident fund Remarks
year (enclose
contribution, etc., to
certificate
which sec. 80C †
issued under
applies (Give details)
section 203)
10 11 12
Value of
perquisite
(column 3
minus
Rent, if any,
Total of columns 4 and column 8
paid by the
6 or column
employee
7 minus
column 8
as may be
applicable)
7 8 9
Interest
credited to the
assessee's
Employer's Total of
account in
contribution to columns 9
recognised
recognised provident to 15
provident fund
fund in excess of 10% carried to
in excess of
of the employee's column 8
the rate fixed
salary [See Schedule of Form
by the Central
IV - Part A] No. 12B
Government
[See Schedule
IV - Part A]
14 15 16