PROFORMA

1. Permanent Account Number(PAN) undersection139(A)of Income Tax Act

Photocopy of PAN Card be attached)
. Premium Towards Life Insurance, f so, attach photocopy of premium paid
during the current financial year.

3. Sum deposited towards 15 Year PPF during current financal year, if so attach
photocopy of receipt.

4. Sum deposited towards ULIP during current F.Y., f so attach copy of recelpt.

Particulars of accommodation, whether reslding in own houseor rented house

or Govt. accommodation. In case of rented house, the amount of rent paid
during the current F.Y. and rent receipts w.e.f. 1 April of Current FY be
attached. Photocopy of PAN Card of the owner of the house be
submitted if the monthly rent is above Rs. 8333/-per month.
6. Deposits towards National Saving Certificates, if so attach proof of such
deposits during current F.Y.

7. Purchase of any Infrastructural Bond or Unit in any Mutual Fund during

Current F.Y., f so attach proof of such purchase.
8. Payments towards 10 Years Jeevan Suraksha Pension Policy/ICICI Life Time
or Forever Life Policy, if so attach copy of receipt.

9 Repayment of HBA/Home Loan borrowed from the Govt. of any Bank or LIC Principle
or National Housing Bank etc. during the current F.Y. (Rebate in repayment
of HBA/Home Loan &interest thereon during current F.Y.) Interest-
10. Tuition Fee paid per annum (for two children)

11. Any other saving in Govt. securities qualified for rebate in Income Tax Act.

12. Any other savings besides above columns.

13. Income from Other Sources i.e. Pension in r/o Ex. Man, Interest
from Fixed Deposits, Recurring Deposits etc.

f NEW REGIME is opted for calculation of Income Tax, there is no need of any saving
Note: documents (S.No. 2 to 12 above.)
DECLARATION
OLD REGTMENEW REGIME
Please tickfor calculation oflncome Tax

Signature of applicant)
Name (Block Letters)
Deslgnation & No._

PIS No.

Place of Posting