INVESTMENT Declaration Form for the period of APRIL 2012 TO MARCH 2013

EMP NAME

PAN No.

EMP NO

Location

DOJ

: Item Praticulars Deduction Under section 10 I am staying in a rented house and I agree to submit rent receipts House Rent when required.The Rent paid is (RS.xxxx for xx months) & the house is located city of .. I have taken exemption for LTA in the following years During the year 2006 - Yes / No During the year 2007 - Yes / No LTA - IF Applicable During the year 2008 - Yes / No as per your CTC During the year 2009 - Yes / No If I do not produce the bills to the satisfaction of the compnay can consider the amount paid towards LTA as taxable

E-mail id Max Limit Declared Amount

MAX BENEFIT PERMISSIBLE (Rs) AMOUNT (RS) 2 Sec 80D Premium in respect of Medical Insurance 15000 (for self, spouce,dependent childern), Addl 15000 is allowed if parents (not a Sr citizens) are covered. Another Addl 5000 is allowed if the parents are Sr citizens Maximum of Rs. 35000/- is allowed under this sec Sec 80DD (Medical treatment of handicapped dependents) Certificate from a doctor working in Government Hospital required Declaration by employee of amount incurred during the year Sec 80DDB (Medical treatment for specified ailments) Government Doctor(not less an MD) certificate in Form 101 Declaration by employee of amount incurred during the year. Please mention if treatment is on Senior Citizen Sec 80E Interest paid on loan availed for higher education Certificate from Financial Institution ( Only Interest part will be given as deduction and not Principal amount) Sec 80U (Physically handicapped or totally blind employee) Certificate from a doctor working in Government Hospital required 0

Maximum limit is 50,000 (In case of severe disablity more than 80% maximum limit is 75,000)

0 40000 or 60000 (Senior Citizen)

No Limit 0 0

5 6

Maximum limit is 50,000 (In case of severe disablity maximum limit is 75,000) Form 12 C is Mandatory to claim this exemption. (Loss should be mentioned in Bracket Eg:(150000))

Income or Loss from house property

0.00 DEDUCTION UNDER SEC 80C 8 Sec 80 CCC Contribution to Pension Fund 9 Life Insurance premium paid 10 Unit Linked Insurance Plan(ULIP) 11 National Savings Certificate(New Purchases) Maximum Limit u/s 80C is 12 Interest Accrued on NSC(Previous Investments) Rs.100000/- (Rs.100000/- including 13 Public Provident Fund(PPF) PF deduction from Salary).Additional 14 Equity Linked Savings Scheme of Rs.20,000/- exemption can be 15 Principle repayment of Housing Loan availed, if the investment is made 16 Mutual Fund Bonds towards infrastructure bonds 17 Tutions fees(Maximum 2 children) 18 Infrastructure Bonds 19 Subscription to the bonds issued by NABARD 20 Fixed Deposits more than 5 years made in Banks Note : The maximum amount of investments qualifying for deducation is Rs. 10,000/- under pension plan - 80CCC 10000 100000 100000 100000 100000 70000 100000 100000 100000 100000 120000 100000 100000

Income other than salary income Deduction under Section 24

If yes, then Form 12C detailing other income is attached

i.e. Interest paid less Net rental income will be Letout property / loss on house property exemption Interest on Housing Loan 150000( for self occupied) Interest if the loan is taken before 01/04/99 For letout (Nett rent-less interest paid will be interest on housing loan) Note : Form 12 C along with the calculation of loss on house property needs to be attached for considering the above Declaration: 1) I hereby declare that the information given above is correct and true in all respects. 2) I also undertake to indemnify the company for any loss/liability that may arise in the event of the above information being incorrect.

Date : Place:

Signature of the Employee