Provisional Declaration for Tax Deduction at Source Financial Year: Name of the Employee: Father's Name: PAN : Detail

of Incomes, Investments and Others [Per Annum] 2012-2013

Sl No
1 2 3 4 5 6 7

Particulars House Rent Paid [Copy of the Rent receipt to be enclosed, if rent per month is more than Rs.3,000/Income from Salary [Other Employer during the year]. Income from House Property [Let out or Un occupied etc.] Interest amout paid towards Housing Loan [Maximum Rs.1,50,000/-] Income from Business or Profession [Consultancy business etc.] Income from Capital Gains [Transfer of Shares, Properties etc.] Income from Other Sources [Interest Income, Lottery, Horse Race etc.]

Amount Invested

U/s VIA [ Per Annum]

Section Sl No
1 2 3 4 5 6 7 8 9 80 CCF 1

Particulars
Investment in LIC/ Other Insurance Premium Investment in Approved Mutual Funds Investment in Public Provident Fund Principal repayment of Housing Loan Stamp duty, registration fee towards transfer of House Property Investment in Pension Funds Tuition fees [Only Tuition Fee excl development fees, donation, etc] NSC VIII Series Subscription to Notified Bonds of NABARD Specified Infrastructure Bond [Maximum of Rs.20,000/-] Medical Insurance Premium for Assessee and/or Parents. Maximum Rs.15,000 for assessee and additional Rs.15,000/- for Parents[Rs.20,000 if senior Citizen]. Premium payment should not be made in Cash. Medical Treatment for Handicapped Dependents. [Maximum of Rs.50,000/- or Rs.1,00,000/- for General Disability and Severe Disability respectively] Medical Treatment Expenditure for Assessee or Dependent. Maximum of Rs.40,000/- for General and Rs.60,000/- for Senior Citizen. Interest payment on Higher Education Loan [Loan is taken for Assessee and his dependent's higher education purpose]. Actual amount of Interest paid for the year. Donations made towards approved organization [PM Releif Fund etc] Maximum of 50% or 100% of the amount donated. Specify along with copy of receipt having PAN number and address of Donee. Physically Handicapped/ Blind Individual Assessee. Maximum of Rs.50,000/- or Rs.1,00,000/- for general and severe disability respectively.[Certificate in Form no. 10-IA to be submitted] Any other Please specify Total

Amount Invested

80 C

80 D

80 DD

80 DDB

80 E

80 G

80 U

Date of Signing

Signature of the Employee