Self Declaration to Avail Income Tax Benefit on House Rent Allowance

(HRA) for Financial Year 2022-23

TO WHOMOSEVER IT MAY CONCENRN

I, ……………………………….……………………………………….. (Employee name), S/o.

………………………………………………………………………, E-code ………………………., do hereby declare
that I have taken undermentioned house property on rent for my residential purpose and
have stayed/would be staying there from__________________ to ___________________. I
therefore want to avail income tax exemption on HRA for the current Financial Year 2022-
23.

I have attached ……………………………. (Rent receipts / relevant extract of my bank

statement) as proof of payment of rent to my landlord for the above said period.

Details of my rented house property are given below:

Name of Landlord: _________________________________________________
PAN of Landlord (PAN copy of landlord to be enclosed): _________________________________
Address of rented house property: _________________________________________________
_________________________________________________
Rent Paid Per Month (INR): _________________________________________________

I hereby confirm that the above given details are correct and true to the best of my
knowledge and belief. In the event of any default, misrepresentation or falsification, I
shall be subject to disciplinary action (including termination from employment) as per the
organization’s Code of Ethics Policy and I shall be solely responsible to face any legal
action that may be taken against me by applicable Statutory Authorities including (and not
limited to) the tax, penalty or interest, as the case may be.

Employee Signature
Employee Name :
Emp. Code :
PAN :