FORM A

NAME OF EMPLOYEE:
(In Block Letters)

EMPLOYEE PAYROLL CODE NO:

(As it appears on the Payslip)

Forms Without Code Numbers Will

NOT be accepted.
3

DATE OF JOINING:

DEPARTMENT:

INCOME-TAX PERMANENT A/C NO. :

(Forms without PAN will NOT be accepted)

As undertaken by me in the Declaration for Income-tax Relief Form signed earlier, I now
attach photocopies copies of receipts in respect of all payments made by me, details as
under:
1.

RENT

(a) I certify having paid (and shall pay) rent for the period April 1, 2016 (or from date of
joining the present company whichever is later) to March 31, 2017 (or to the Date of
Leaving the current company which ever is earlier) totalling Rs. _____________
(b) No. of rent receipts attached _________________________
(c) PAN OF LANDLORD _____________________________ ( PAN of Landlord is
Compulsory if Rent is More than Rs.1,00,000 per annum or part thereof )

2.

SECTION 80 CCC JEEVAN SURAKSHA / OTHER PENSION SCHEMES

(Maximum of Rs.1,50,000)
I certify having paid from my income of the year chargeable to tax, premium of Rs._________
I am attaching herewith copies of receipt marked as Annexure No.____________.

3.

SECTION 80D - MEDICAL INSURANCE PREMIA

(a) I certify having paid during the year medical insurance premia for Myself / Spouse /
Dependant Children totalling Rs. _____________

Annexure marked No.

_________
(Maximum. Rs.25,000 or Rs.30,000 if any one of the above is a Senior Ctiizen.)
If you or your spouse is a senior Citizens (60 Years or above) please tick mark box >>
(b) I certify having paid during the year medical insurance premia for My Parents
totalling Rs. ______________ Annexure marked No. ____________
(Maximum. Rs.25,000 or Rs.30,000 if any parent above is a Senior Ctiizen.)
If any parents is a senior Citizens (60 Years or above) please tick mark box >>>
The Total of 3(a) and 3(b) above totalling to Rs. ______________.
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4.

SECTION 80U Disability OR Section 80DD OR 80DDB Handicapped

I certify having incurred and paid expenses pertaining to a disability as per these sections and
as per the Rules qualified therein. Rs._______________ Annex No. ______________
Please provide certificate mentioning the Percentage of Disability here as Annex No. ______.
Also Attach a valid copy of the Certificate issued by the required Medical Authority as Annex.
No,__________. No Relief will be given if failure to attach either certificate.

5.

SECTION 80 E INTEREST PAYABLE IN RESPECT OF EDUCATION LOAN

I certify having taken an education Loan as per the Provision of this section. The amount
mentioned here pertains ONLY TO THE INTEREST PORTION OF THE LOAN
Rs.____________________.

6.

being

As Per Annexure No. _________________________.

LOSS UNDER THE HEAD INCOME FROM HOUSE PROPERTY

(To be filled in when employee lets out any house property during the year)

I have incurred an aggregate loss under the head Income from house property
Rs.________
I attach herewith a computation of the same as an Annexure No. _________to this
declaration along with copies of all relevant receipts e.g. rent receipts issued to the tenant,
municipal taxes, ground rent receipts, copy of lease agreement, etc. The onus of correct
computation in this point is solely the responsibility of the Employee and the Employer
will not be held accountable for the same.
7.

INTEREST PAID IN RESPECT OF SELF-OCCUPIED HOUSE PROPERTY

(to be filled in only when employee has not let out any house property during any
duration during the year - maximum amount eligible for deduction is Rs.2,00,000)

I certify having paid Rs._______________ for the year ending 31st March, 2017, as interest
on loan taken for acquiring OR constructing my self-occupied property situated at:
___________________________________________________________________________
___________________________________________________________________________

I furnish herewith a receipt from the lender Annexure No. __________ of the interest paid for
the year, along with the Permanent Account Number and the address of the Lender.
I confirm that the aforesaid house property or any portion thereof has not been let out during
any period of the year and no other benefit has been derived from it by me.
(Maximum of Rs.2,00,000)

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8.

ST

INTEREST PAID IN RESPECT OF NEW 1

TIME SELF-OCCUPIED HOUSE
PROPERTY - Maximum amount Eligible Rs.50,000 pa.
(to be filled in only when employee has not let out any house property during any
duration during the year the LOAN cannot Exceed Rs.35 Lakh and Value of
Property does not Exceed Rs.50 Lakh.

I certify having paid Rs._______________ for the year ending 31st March, 2017, as interest
on NEW FIRST TIME LOAN taken for acquiring OR constructing my self-occupied property
situated at:
___________________________________________________________________________
___________________________________________________________________________

I furnish herewith a receipt from the lender Annexure No. __________ of the interest paid for
the year, along with the Permanent Account Number and the address of the Lender.
I confirm that the aforesaid house property or any portion thereof has not been let out during
any period of the year and no other benefit has been derived from it by me.
(Maximum of Rs.50,000)

9.

UNITS OF MUTUAL FUND AS PER SEC 10 (23D) APPROVED BY THE CBDT

I certify having paid from my income of the year chargeable to tax, towards the
following:
(Maximum of Rs.1,50,000)
Allotment Letter No./ Date of Allotment
Amount
Name of Mutual Fund
Share Certificate No.

Total Rs.

I am attaching herewith copies of allotment letter/share certificate marked as Annexure

No.___________

10.

FIXED DEPOSIT WITH SCHEDULE BANK MORE THAN 5 YEARS:

(Maximum of Rs.1,50,000)
Name of Bank
Fixed Deposit No.
Date of Allotment
& Date of Matuity

Amount

Total Rs.
(Maximum of Rs.1,50,000)
I am attaching herewith copies of the Fixed Deposits marked as Annexure No.___________
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11.

LIFE INSURANCE PREMIA / JEEVAN DHARA / JEEVAN AKSHAY ANY OTHER

LIFE INSURANCE POLICY:

I certify having paid, from my income of the year chargeable to tax, insurance premia, details
as under:
(Maximum of Rs.1,50,000)
Policy No.
Date of Payment
Premia Amount
Vr. No.

Total Rs.
PLEASE DO NOT ATTACH COPIES OF POLICIES. ONLY PHOTOCOPIES OF RECEIPTS
OF PREMIA PAID SHOULD BE ATTACHED. ALL PREMIA RECEIPTS SHOULD
REFLECT DATES BETWEEN APRIL 1st, 2016 TO MARCH 31st, 2017.

12.

ULIP/DHANRAKSHA

I certify having paid, from my income of the year chargeable to tax, premiums towards my
ULIP/DHANRAKSHA policies, details as under:
(Maximum of Rs.1,50,000)
Policy No.
Date of Payment
Premia Amount
Vr. No.

Total Rs.

13.

PUBLIC PROVIDENT FUND (PPF) - Max. Rs.1,50,000

I certify having paid, from my income of the year chargeable to tax, deposits into my PPF
Account No. ________________, details as under:
Vr. No.

Date of Payment

Deposit Amount

Total Rs.

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14.

HOUSING LOAN REPAYMENT - Max. Rs.1,50,000

I certify having repaid during the year housing loan taken by me from
__________________________________________ totalling Rs. _______________I further
certify that this amount represents the payment towards the principal amount only and does
not include payment of any interest. The relevant certificate is attached herewith and marked
Annexure. No. __________. (Maximum of Rs.1,50,000)

15.

NATIONAL SAVINGS CERTIFICATES SERIES

I certify having purchased, from my income of the year chargeable to tax, the under
mentioned NSC Issue: (Maximum of Rs.1,50,000)
Vr. No.

Date of Payment

Deposit Amount

Total Rs.

16.

ACCRUED INTEREST ON NSC SERIES

I certify that the interest accrued in respect of my NSC for the year ending March 31, 2017 is
Rs. ___________________.
I give below the year wise detailed working of the interest accrued in support of the above
stated amount:- (Maximum of Rs.1,50,000)
Date of Purchase
NSC Deposit Amount
Accrued Interest
NSC Cert. Number

Total Rs.

17.
TUTION FEES PAID (Max. 2 Children, Please refer Income Tax Rule)
(Maximum of Rs.1,50,000)
Vr. No.
Particulars
Date of Payment
Amount Paid

Total Rs.

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SUKANYA SAMRIDDHI SCHEME: (Up to a maximum of Rs.1,50,000)

18.
Vr. No.

Date of Payment

Deposit Amount

Total Rs.

19.
NATIONAL PENSION SCHEME U/S 80CCD(1):
Rs.1,50,000)
Vr. No.

(Up to a maximum of

Date of Payment

Deposit Amount

Total Rs.

20.

NATIONAL PENSION SCHEME U/S 80CCD(1B): (Up to a maximum of Rs.50,000)

Vr. No.

Date of Payment

Deposit Amount

Total Rs.

21.
Vr. No.

INFRASTRUCTURE BONDS: (Up to a maximum of Rs.1,50,000)

Date of Payment

Deposit Amount

Total Rs.
I hereby declare that the information given above is correct and true in all respects. I request
the Company to allow me the appropriate Income-tax rebate/relief. If any of the above details
is incorrect, the Company will not be responsible or liable to any tax liability on behalf of the
employee.
Signature Of Employee:

__________________________________

Name (in block letters):

__________________________________

Signature of Regional/Location Manager,

H.R. / Finance/ Local Finance functionary:
confirming that the detail and documentary
--------------------------------------------------evidence contained in this form have been
checked and verified with originals and are found to be in order.

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