Self Declaration for Mobile and Broadband Bill

I ___________________________________ s/o/d/o___________________________
r/o_________________________________________________________________________
___hereby declare that, the following Mobile payment/(s) due date(s) fall after the cutoff
date for submission of investment proofs i.e. 03rd January 2023.

I do hereby take the responsibility in submitting the actual summary of Invoices and
Payment on or before 7th March 2023 to Company, otherwise, I authorize Company to
revoke the tax exemption provided to me earlier based on this declaration. I understand that
I will not claim any amount in this relation to revocation of the tax exemption from Company
thereafter.

Note:
1. The Post-Paid Telephone/ Mobile Bills in the name of the employees only can be
submitted. Submit the invoice/bill copy for all the months claimed.
2. Maximum 2 mobile numbers

Particular Number

Mobile number

Enclosures:
Sl. No. Bill/ Receipts No. & Date Tel/ Mobile No. Amounts (Rs.)
1
2
3
4
5
6
7
8
9
10
11
12
Total

Date: (Signature of the employee)