INCOME TAX DECLARATION FORM Assessment Year 2012-2013 Financial Year 2011-2012 Dear Sir/Madam On The Basis of your

Current Salary of Rs --------------------- per month. Your Tax Liability Comes to Rs. ----------------------Monthly Deduction would be Rs. ---------------------Please fill up the attached form and submit till 31-05-11. So the deduction should be made accordingly. 1. 2. 3. 4. 5. Employee Code No. --------------------- -------- Date of Joining --------------- Date of Birth ---------------------Name ------------------------------ Fathers Name ------------------------------------------------------Designation ------------------------------ Department/Site ---------------------------------------------------Residential Address ---------------------------------------------------------------------------------------------------------Permanent Account No. (PAN)------------------------------------ Contact No. -----------------------------------------------(As per Finance Act, 2001 the employees must give their PAN No. to get Form 16 from the Company. In case someone doesnt have PAN No, he / she should apply in Form 49A to INCOME TAX DEPARTMENT) Total Premium payable on L I. P. during the year 01.04.2011 to 31.03.2012 (attach receipts) Policy No. Sum Assured Premium Payable Rs. Rs. ________________________ Rs. Rs. ________________________ Contribution to Equity linked Savings Scheme of a Mutual Fund Rs. Deposit in 10/15 year CTD (Post Office) Rs. Contribution to Public Provident Fund (PPF) Rs. Contribution to Statutory / Recognized Provident Fund (SPF/RPF) Rs._________________________ Subscription to NSC VIII th Series Rs. Contribution to Unit Linked Ins. Plan (ULIP) Rs. Interest on NSC invested earlier (give details) Rs. Repayment of Principal amount for Loan for Purchase / Const. Rs. Of House (enclose Banks Certificate) Date of completion / purchase of Property. (Attach copy of completion / possession certificate issued by Competent Authority) School fees of Children paid during the year Fees for First / One Child Rs. _______________________ Fees for Second Child Rs. _______________________ Contribution for Annuity Plan of LIC Pension Rs. _______________________ Amount deposited in a Fixed Deposit for 5 years or more with a scheduled bank in accordance with the scheme framed Rs. _______________________ Subscription to any notified bonds NABARD. Rs. _______________________
Investment in longterm infrastructure bonds notified by the Central Government upto Rs. 20,000 is allowed as deduction over and above the existing limit of Rs.1 lakh on tax savings. Rs.________________________

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Payment of Mediclaim insurance premium (Sec.80D) Rs. _______________________ Expenditure for medical treatment of handicapped dependent (Sec. 80DD) Rs. _______________________ Repayment of interest on Education Loan (Sec. 80E) Rs. _______________________ Repayment of interest amount paid for Loan for Purchase / Construction Rs. _______________________ Of House (enclose Banks Certificate) Date of completion / purchase of Property (Attach copy of completion / possession certificate issued by Competent Authority Monthly Rent paid to Landlord Rs._______________________ i ) Mention city/town (In which city located the house). --------------------ii ) Attach rent receipt from April 2011 or from the first month of joining during FY 2011-12 to March, 12) Confirm that I have spent at least Rs.800 per month on transport on commuting between office and residence:------yes/No)

I declare that the above information given is true and correct to the best of my knowledge. Any change in the above information will be intimated immediately. I further declare and understand that proof of investments made during the year 2011-12 will be submitted to the Accounts Department and if the same is not submitted latest by 25.02.12 TDS calculations will be made on the basis of proofs available with the Accounts Department. I agree to indemnify the Company of any Income Tax interest that the Company may become liable in view of my declaration provided being wrong. I also declare and confirm that the amount invested in respect of which I have claimed rebate / deduction under the Income tax Act, 1961 will be made out of my income chargeable to tax during the above financial year 2011-12 and as per the stipulations laid out under the Income Tax Act. Place : Date : Signature 1. 2. NOTE : SL. NO.1 TO 5 IS COMPULSORY TO FILL. NOTE: ALL NEW EMLPOYEES (JOINING DURING THE F.Y.2011-12) MUST PROVIDE FORM-16 RECEIVED FROM PREVIOUS EMPLOYER.