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1) Are you drawing House Rent Allowance (HRA) from University
If yes, then
a)please specify rent paid to the land lord per year

Note: If rent paid is more than Rs.3000/- per month please
attach rent receipt from the landlord.

2) Whether you have taken Housing Loan (For Construction Only) YES/NO
If yes, then
a) Is it taken before 01/04/1999 or after
b) Interest Paid/Payable in 2009-10 (Upto 31/03/2010)
b) Principal Paid/Payable in 2009-10 (Upto 31/03/2010)
Note: 1) Pl. attach a certificate to the above effect from the
Bank/Financer/Staff Housing Loan of TU stating the interest
and principal paid/payable from 01/04/2009 to 31/03/2010)
Note: 2) Personal or other loan taken for house construction
or repair of existing house will not qualify for deduction

Whether you hold any Life Insurance/Annuity Policy of any Life
3) Insurance Company in India either in your/your spouse/your YES/NO
children's name
If yes, then provide:

Policy No. Premium Paid/Payable in 2009-10

Note: Please attach copy of premium payment receipt for all
the above policies. Please do not provide information on Salary
Saving Policies.

Whether you have purchased any of the following financial
instruments in 2009-10 (or planning to purchase within 31/03/2010)
If yes, then give details:

If yes. a) ULIP (Premium Paid/Payable) of Unit Trust of India b) ULIP (Premium Paid/Payable) of LIC Mutual Fund c) NSC (VIIIth Issue) d) Amount Deposited in Public Provident Fund (PPF) e) Any Contribution made to Equity Linked Savings Scheme (ELSS) f) Tuition Fees of Children (Except where it is not reimbursed/ reimbursible by TU under Children's Educational Allowance) g) Fixed Deposit in any scheduled Bank for not less than 5 Years made in 2009-10 h) Premium paid in 2009-10 towards Postal Life Insurance (PLI) i) Premium paid in 2009-10 for any Pension Plan of any Life Insurance Company in India Note: Please attach the proof of above payments.e. then give details of premium paid in 2009-10 a) For Self b) For Spouse c) For Children d) For Parents (Who are not Senior Citizen) e) For Parents (Who are Senior Citizen) Note: Please attach the proof of above payments.. then give details of interest payment Note: Please attach certificate stating the interest paid/payable in 2009-10 from the Bank/financial institution . if any Whether you have paid premium towards any Health Insurance for 4) self/spouse/children/parents and whether your parents are senior YES/NO citizen. i. then give details of expenditure/premium paid Note: Please attach certificate from competent medical officer. aged more than 65 Years of age (Mediclaim Policy) If yes. if any Whether you have incurred any non-reimbursible expenditure on medical treatment of/paid premium of any medical insurance for 5) YES/NO your dependent disabled Spouse/children/parents/brothers/ sisters. etc. if any Whether you have paid/will pay interest in 2009-10 on any 6) educational loan taken for your own higher studies to any YES/NO bank/financial institute If yes.

B. ANY INFORMATION SUBSEQUENTLY FOUND TO BE WRONG / INCORRECT SHALL BE THE SOLE RESPONSIBILITY OF THE EMPLOYEE CONCERNED. .: If the space is not sufficient please attach separate sheet for any item as above. 7) Whether you have paid any donation to any approved Trust/Fund YES/NO If yes.T. Act 8) Whether you are physically handicapped employee YES/NO Note: Please attach certificate from Authorised Medical Officer for the above. N. then give details of such payment Note: Please attach proof of payment (copy of receipt) wherein it should be specified that the said Trust/Fund is eligible under Sec-80G of I. Signature of the Employee Employee ID PAN Number (Compulsory) NOTE: THE INFORMATION FURNISHED BY THE INDIVIDUAL EMPLOYEE WILL BE CONSIDERD BY THE AUTHORITY AS CONCLUSIVE.