Declaration to be filed by a person who does not have Permanent Account Number

1 Full Name and address of the declarant

2 Particulars of transaction Rental Income
3 Rent (Per Annum)
4 Are you assessed to tax? Yes/No
5 If yes,
(i) Details of Ward/Circle/Range (Where
the last return of income was filed):


Verification:
I,_____________________________________________________________________ _______ _______
Son/Daughter of ______________________________________________ aged ______ years do hereby
declare that I am the sole / joint owner of the residential property address - ______________________
____________________ _______________________ ___________ ___ which i had given on rent to
Mr/Ms ___________ ___________ ______ _____ ____________ _________ ______ ________________
for monthly rent of Rs.____________/-(In words Rs. _________________________________ ________
_____________________ _______________) effective from __________

I, further confirm that I do not have Permanent Account Number (PAN) issued by the tax authorities in
India. This declaration is issued to enable my tenants (as named above) employer to claim HRA
exemption under the Income Tax Act in the absence of my PAN.
The above information is true and correct to the best of my knowledge and I shall be personally
responsible and liable if the same is found to be incorrect.

Signature/s
Name/s
Date : Place :