Professional Documents
Culture Documents
2014
NAME OF COMPANY: EMPLOYEE CODE NO.
(As appears on the Pay Slip)
LOCATION: PAN:
(Form without PAN is INVALID)
NAME OF EMPLOYEE:
SEC.80D - MEDICLAIM PREMIUM (Max. Rs.35,000 = 15,000 + 20,000 ) Sec.80DD Handicapped or Sec.80U Disability SEC. 80CCC - JEEVAN SURAKSHA / OTHER PENSION SCHEMES 80E - EDUCATION LOAN INTEREST (Only Interest Component) LOSS UNDER THE HEAD "INCOME FROM HOUSE PROPERTY" INTEREST PAID IN RESPECT OF SELF-OCCUPIED PROPERTY
Interest on Loans taken after 01.04.1999 (Max. Rs.1,50,000)
INTEREST PAID IN RESPECT OF NEW SELF-OCCUPIED PROPERTY (Loan taken after 01.04.2013 & Loan Less than 25 Lakh.) UNITS OF MUTUAL FUND [ Section 10(23D) ]
10 FIXED DEPOSIT WITH SCHEDULE BANK MORE THAN 5 YEARS. 11 LIFE INSURANCE PREMIA (by LIC or any other Insurer) - LIP 12 ULIP / DHANRAKSHA 13 PUBLIC PROVIDENT FUND - PPF (Max. Rs.1,00,000) 14 HOUSING LOAN REPAYMENT - PRINCIPAL AMOUNT 15 NATIONAL SAVINGS CERTIFICATE SERIES - NSC 16 ACCRUED INTEREST ON NSC 17 TUITION FEES PAID TO UNIVERSITY, COLLEGE, SCHOOL 18 INFRASTRUCTURE BONDS (As per old Scheme)
I hereby declare that the information given above is correct and true in all respects and I request the company to allow me the appropriate Income-tax exemption / relief. I undertake to produce to the company, LATEST BY JANUARY 1, 2014, OR prior to leaving the company, appropriate documentary evidence in respect of payments mentioned above. Failing this, I agree that the company wil be free to cancel the exemption allowed and to recover from me the additional Income-tax arising there from.
Signature of Employee:
(Form without SIGNATURE is INVALID)
Date: