HRA Declaration Form

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HRA Declaration form (FY 2016-17)

I hereby declare that I am residing on rent in the accommodation as detailed here below:-

1 Owners name

2 Period of Accommodation

From date: To date:

3 Address of premises residing in

4 Amount of Rent paid per month

5 PAN No. of House-Owner

I also enclose herewith the rent receipts evidencing payment of rent for the aforementioned period and also
undertake to submit additional proof of the same in the event of the same being required by the Income Tax
authorities.

Employee Signature

Employee Name ( as per Company records)

Employee Code (as per Company records)

Employees location

Dated

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