Declaration to obtain deductions from Total Taxable Income for the FY 2011 - 12

Emp No PAN
Employee Name Address
Date of Joining

1 To qualify for deduction of House Rent allowance, I hereby declare that during April 2011 to March 2012, I will be paying a
monthly rent of Rs.
2 I will be paying Rs.____________________ by cheque towards the Medical Insurance Premium under Sec 80 D.
[ Insurance taken on self, spouse, children and dependent parents and dependent children - Max of Rs.35,000 ]

3
I will be incurring Rs._____________________ towards maintenance including medical treatment of a dependent who is a
person with disability u/s 80 DD [ Max of Rs.50,000 and it is Rs.75,000 if the dependent is a person with sever disability ]

4 I will be incurring Rs._____________________ towards medical treatment of specified disease or ailment prescribed in IT
Rules u/s 80 DDB [ incurred for self or dependent - Max of Rs.40,000 and for senior citizens - Max Rs.60,000 ]

5 I will be repaying Rs.______________________ towards repayment of Educational loan taken for higher education from
___________________________________________bank u/s 80 E [ Only Interest Portion ]
6
I will be paying Rs. towards interest on Housing Loan taken from bank towards purchase / construction of
house property. Further, I hereby confirm that the said house is occupied by me and not rented out during FY 2011-12.

7
I am eligible for the deduction of Rs._______________, u/s 80U-Deduction in case of a person with disability. I will be
providing the necessary certificate for the same. (Rs.50,000 for person suffering from not less than 40% of any disability. A
higher deduction of Rs.75,000 will be allowed in case of severe disability.

8
The Expenditure on account of my medical treatment or treatment of member/s of my family during the financial year 2011-
2012 would amounts to Rs_______________________. I hereby undertake to provide the original bills for the medical
expenditure incurred

9 To qualify for deduction from income, I will be investing the following sums, out of the chargeable income
[ Allowed only on payment basis ]
a PF Contribution [12% of Basic+VDA]
b Contribution to Pension Funds U/s 80 CCC
c LIC Premium [ taken on self, spouse, children and a married daughter ]
d Contribution to notified pension fund set up by Mutual Fund or UTI
e Contribution to 15 Year Public Provident Fund (Max Rs.70,000)
f Subscription to National Savings Certificates, VIII Issue
g Contribution to Unit-Linked Insurance Plan (ULIP) of UTI
h
Contribution to Unit-Linked Insurance Plan (ULIP) of the LIC Mutual Fund
i Amount deposited in a fixed deposit for 5 years or more with scheduled bank in
accordance with a scheme framed and notified by the Central Government
j Payment for notified annuity plan of LIC (i.e., New Jeevan Dhara & New
Jeevan Akshay, New Jeevan Dhara I, New Jeevan Akshay I and New Jeevan
Akshay II)
k Subscription towards notified units of Mutual Fund or UTI
l Tuition Fees paid for the education of children
m Repayment of Housing Loan Principal taken from ____________________
bank towards purchase/construction of house property. Further, I hereby
confirm that the said house is occupied by me and not rented out during the
year

Total Investment [ Max of Rs.100,000 ] -

10
I am eligible for the deduction of Rs.____________, u/s 80CCF-Deduction in case of investment in Long Term Infrastructure
Bonds. I will be providing the necessary certificate for the same.

I declare that the aforesaid investments will be made out of my current years income chargeable to tax
I further undertake to inform the company in writing if there are any changes in any of the figures declared above during the year

I also undertake to indemnify in the event of the company being called upon to pay any tax or penalty or interest due to the deficiency of
my above declaration
I am attaching Form-12B, giving details of my previous employment along with Tax Computation sheet or Form-16 issued by my
previous employers [ As Applicable ]
Date :
Place : Signature_______________________________

IT Declaration Format 2010-11 Page 1

For Individuals the Tax Rates as below for the FY 2011-12.

Income Rate of Income Tax

*Upto Rs.1,80,000 NIL

Rs.1,80,001 to Rs.5,00,000 10% Income Above Rs.1,80,000
Rs.5,00,001 to Rs.8,00,000 Rs.32,000 +20% of Income Above Rs.5,00,000
Rs.8,00,001 and Above Rs.92,000+30% of Income Above Rs.8,00,000

For Women NIL

Income Rate of Income Tax

*Upto Rs.1,90,000 NIL

Rs.1,90,001 to Rs.5,00,000 10% Income Above Rs.1,90,000
Rs.5,00,001 to Rs.8,00,000 Rs.31,000 +20% of Income Above Rs.5,00,000
Rs.8,00,001 and Above Rs.91,000+30% of Income Above Rs.8,00,000

Note:
1.Education Cess @3% as applicable