RELIOBRIX CONSULTING PVT LTD

"INCOME TAX DECLARATION FORM" F.Y. 2019-20

All below details are MANDATORY

EMPLOYEE NAME PAN CARD NO.

EMPLOYEE ID CONTACT NUMBER

DOJ DIVISION

DEPARTMENT EMAIL ID (OFFICIAL)

REPORTING MANAGER
RESIDENTIAL ADD.
TEAM HEAD

I hereby declare that the following investment will be made by me during the financial year 2019-2020 starting from
1st of April 2019 to 31st of March 2020
PART A - Investments proposal u/s 80 C (Maximum Amount Upto Rs 150,000/-)

S.NO. Under Section 80 C Document to be furnished by Employee Amount (Rs)

1 LIC Premium Copy of Premium Payment Receipt

2 Contribution to Public Provident Fund (PPF) Copy of Challan and Passbook

3 Subscription to National Saving Certificates (NSC) VIII issue Copy of Certificate issued by Post Office

4 Tution fee for full time education in India upto a maximum of two childeren Copy of Tution Fee Receipt

5 Contribution to Unit Linked Insurance Policy (ULIP) Copy of payment receipt

6 Repayment of Housing Loan (Principal Amount) Copy of certificate issued by Housing Loan Co.

7 Contrribution to notified mutual funds - ELSS Copy of statement issued by Mutual Fund Co.

8 Premium towards Pension Plan (80CCC) Copy of Premium Payment Receipt

9 Fixed deposits for 5 years or more in a scheduled Bank FD certificate issue by Bank

TOTAL INVESTMENTS U/S 80C -

PART B - Investments proposal under Section 80D :

S.NO. Under Section 80D/80U/80DD/80DDB/80E Document to be furnished by Employee Amount (Rs)

1 80D - Premium paid towards Mediclaim Policy Premium Receipt issued by the Insurance Co.

2 80U for Handicapped self Certificate issued by physician, Surgeon, psychiatrist working in Govt
Hospital
3 80DD for Handicapped dependent Certificate issued by physician, Surgeon, psychiatrist working in Govt
Hospital
4 80DDB for self o relative for specified diseases Certificate in Form 10IA by Doctor registered with IMA with post
graduation qualification only

5 80E for Repayment of Education Loan (only Interest Payment)(for self Education) Certificate of Payment from Bank

PART C - Housing Loan

Repayment of Interest on housing loan (Max Rs. 200000/-) u/s 24(1)(b) in case of Self
1 Copy of certificate issued by Housing Loan Co.
Occupied House Property. Please refer to instructions.

Dual benefit of HRA & Housing Loan Interest can be taken only if both are
2 Address of Property for which House Loan Obtained
situated in different satelite town.

PART D - Income other than salary

1 Other income (specify if any) Rent, salary from other employer, Bank interest, Capital Gains etc..

PART E - HRA Exemption U/S 10(13A)

S.No. Address of Rented Premises Rent per month From Date To Date Total Rent

Total Rent Paid/ Payable in the year

I __________________________________________ undertake that the proposed investments/savings mentioned above will be completed and documentation in this regard will be
submitted to accounts department on or before September 30, 2019 for final computation of income tax for the year 2019-20.
In case proof of investment/payment is not provided by the date specified, income-tax may be deducted as applicable.
I Shall Idemnify Reliobrix for all cost and consequences if any information found to be incorrect.
I further declare that in case of any change in above declaration, I would inform to the company.

Date: Signature of the Employee