FORM A

1 NAME OF EMPLOYEE:
(In Block Letters)

2 EMPLOYEE PAYROLL CODE NO:

(As it appears on the Payslip)
Forms Without Code or Wrong
Numbers Will NOT be accepted.
3 DATE OF JOINING:

4 DEPARTMENT:

5 INCOME-TAX PERMANENT A/C NO. :

As undertaken by me in the ‘Declaration for Income-tax Relief Form’ signed earlier, I now
attach Xerox copies of receipts in respect of all payments made by me, details as under:

1. RENT

(a) I certify having paid (and shall pay) rent for the period April 1, 2010 (or from date of
joining the present company – whichever is later) to March 31, 2011 totalling Rs.
_____________

(b) The name and address of my landlord/lady to whom I have paid my rent is :
__________________________________________________________________________
__________________________________________________________________________
_____________________________________________________

(c) No. of rent receipts attached _________________________

2. SECTION 80D - MEDICAL INSURANCE PREMIA

I certify having paid during the year medical insurance premia totalling Rs. ______________

I am attaching herewith the receipt marked Annexure No. ____________.

3. SECTION 80 CCC JEEVAN SURAKSHA / OTHER PENSION SCHEMES

I certify having paid from my income of the year chargeable to tax, premium of Rs._________

I am attaching herewith copies of receipt marked as Annexure No.____________.

4. LOSS UNDER THE HEAD “INCOME FROM HOUSE PROPERTY”

(To be filled in when employee lets out any house property during the year)

I have incurred an aggregate loss under the head “Income from house property”
Rs.________

I attach herewith a computation of the same as an Annexure No. _________to this

declaration along with copies of all relevant receipts e.g. rent receipts issued to the tenant,
municipal taxes, ground rent receipts, copy of lease agreement, etc.)
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5. INTEREST PAYABLE IN RESPECT OF SELF-OCCUPIED HOUSE PROPERTY
(to be filled in only when employee has not let out any house property during any
duration during the year - maximum amount eligible for deduction is Rs.1,50,000/-)

I certify having paid Rs._______________ for the year ending 31st March, 2011, as interest
on loan taken for acquiring, constructing or repairing my self-occupied property situated at:
___________________________________________________________________________

___________________________________________________________________________

I furnish herewith a receipt from the lender Annexure No. __________ of the interest paid for
the year, along with the Permanent Account Number and the address of the Lender.

I confirm that the aforesaid house property or any portion thereof has not been let out during
any period of the year and no other benefit has been derived from it by me.

6. UNITS OF MUTUAL FUND AS PER SEC 10 (23D) APPROVED BY THE CBDT

I certify having paid from my income of the year chargeable to tax, towards the
following:

Name of Mutual Fund Allotment Letter No./ Date of Allotment Amount

Share Certificate No.

Total Rs.

I am attaching herewith copies of allotment letter/share certificate marked as Annexure

No.___________

7. FIXED DEPOSIT WITH SCHEDULE BANK MORE THAN 5 YEARS:

Name of Bank Fixed Deposit No. Date of Allotment Amount

& Date of Matuity

Total Rs.

I am attaching herewith copies of the Fixed Deposits marked as Annexure No.___________

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8. LIFE INSURANCE PREMIA / JEEVAN DHARA / JEEVAN AKSHAY ANY OTHER
LIFE INSURANCE POLICY:

I certify having paid, from my income of the year chargeable to tax, insurance premia, details
as under:

Vr. No. Policy No. Date of Payment Premia Amount

Total Rs.

PLEASE DO NOT ATTACH COPIES OF POLICIES. ONLY PHOTOCOPIES OF RECEIPTS

OF PREMIA PAID SHOULD BE ATTACHED. ALL PREMIA RECEIPTS SHOULD
REFLECT DATES BETWEEN APRIL 1st, 2010 TO MARCH 31st, 2011.

9. ULIP/DHANRAKSHA

I certify having paid, from my income of the year chargeable to tax, premiums towards my
ULIP/DHANRAKSHA policies, details as under:

Vr. No. Policy No. Date of Payment Premia Amount

Total Rs.

10. PUBLIC PROVIDENT FUND (PPF) - Max. Rs.70,000

I certify having paid, from my income of the year chargeable to tax, deposits into my PPF
Account No. ________________, details as under:

Vr. No. Date of Payment Deposit Amount

Total Rs.

11. HOUSING LOAN REPAYMENT

I certify having repaid during the year housing loan taken by me from
__________________________________________ totalling Rs. _______________I further
certify that this amount represents the payment towards the principal amount only and does
not include payment of any interest. The relevant certificate is attached herewith and marked
Annexure. No. __________. (Maximum of Rs.1,00,000)
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12. NATIONAL SAVINGS CERTIFICATES SERIES VIII ISSUE

I certify having purchased, from my income of the year chargeable to tax, the under
mentioned NSC VIII Issue:

Vr. No. Date of Payment Deposit Amount

Total Rs.

13. ACCRUED INTEREST ON NSC VIII SERIES

I certify that the interest accrued in respect of my NSC (VIII Issue) for the year ending March
31, 2011 is Rs. ___________________.

I give below the year wise detailed working of the interest accrued in support of the above
stated amount:-

NSC Cert. Number Date of Purchase NSC Deposit Amount Accrued Interest

Total Rs.

14. TUTION FEES PAID (Max. 2 Children, Please refer Income Tax Rule)

Vr. No. Particulars Date of Payment Amount Paid

Total Rs.

15. INFRASTRUCTURE BONDS: (Up to a maximum of Rs.1,00,000)

Vr. No. Date of Payment Deposit Amount

Total Rs.

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16. INFRASTRUCTURE BONDS u/s 80CCF: (Up to a maximum of Rs.20,000)

Vr. No. Date of Payment Deposit Amount

Total Rs.

17. ANY OTHER TAX SAVINGS SCHEME – Please give full details and Relevant
Section under which relief is to be given:

Details as under:
Vr. No. Name Of the Scheme Under Section Amount Deposited

Total Rs.

I hereby declare that the information given above is correct and true in all respects. I request
the Company to allow me the appropriate Income-tax rebate/relief.

Signature Of Employee: __________________________________

Name (in block letters): __________________________________

Location: __________________________________

Signature of Regional/Location Manager,

H.R. / Finance/ Local Finance functionary:

_________________________________
confirming that the detail and documentary
evidence contained in this form have been
checked and verified with originals and are found to be in order.

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