INCOME TAX DECLARATION for Financial Year 2015-16 (Assessment Year 2016-17)

Employee's Name Sumit Goel Date 14-Jul-15

Employee Code 2015005 Extn No 593
Department Layout & Piping Location/Floor Intec House/Lower Ground
Mobile No. 8800478947 Date of Joining 2-Feb-15
Address D-177, Sector-30, Jalvayu Vihar. Gurgaon Date of Birth 24-Jan-81
PAN No : AKOPG6225H Gender Male
The undermentioned amounts may be considered for computation of my Income Tax Liability :
Amount Rs.
1 Exemption in respect of House Rent Allowance u/s 10(13A) (Before filling please refer note given at the end of S. No.2)
City of Rented Accomadation Gurgaon Rent paid per month 24000
Plz specify PAN of Owner, if Rent paid during year Rs 100000 or more (i.e Rs. 8333/- PM or more) ADEPG2551M
2 Deduction u/s 24(b) for Interest on Housing Loan (please attach provisional certificate arranged from your Bank/Financial Institution)
(a) Complete Address of House property
(b) If Loan is taken to construct House Property, specify: (i) Date of completion of construction
(ii) Interest on housing loan for the current Financial Year
(iii) 1/5 th of pre-construction period Interest which is eligible for deduction over 5yrs starting from the year of completion
or
(c) If Loan is taken to purchase a ready build house, specify: Interest on housing loan for the current Financial Year
or
(d) If Loan is taken for repair, renewal or reconstruction of above house, specify: Interest on loan for the current Financial Year
(e) Whether property is self occupied or Let-out Select
If let out, please specify: (i) Actual Annual Rental income
(ii) Fair Annual Rental value of similar accomodation in same location
Note: Out of 'HRA exemption' and the 'Deduction for Interest on Housing loan as self occupied', only one can be availed except in a case where house property
could not be used owing to employment at any place other than where house property is located. For exact understanding of relevant provisions, please read
'Note on Housing Loan Benefits or Housing Loan Benefits as well as HRA Exemption' attached herewith. And in case you are to avail HRA exemption & Housing
Loan Benefits both or in case you own more than one House property or own the house property/housing loan in joint name, please also attach the duly filled
additional details for HRA & Housing Loan Benefits with your declaration in format given in the next sheet available in this file.

3 Deduction u/s 80C (Maximum investment of Rs.1.5 lacs including employees contribution to PF)
(a) Life Insurance premium paid for self, spouse & children (please attach summary at the top while submitting proofs) 40,035
(b) Repayment of Housing Loan, any instalment or part payment towards cost of purchase/construction of new residential property including payment of stamp
duty, registration fee and other expenses for purpose of transfer
(c) Tution Fees paid for full time education of two children (only tution fee component to be considered here) 67500
(d) PPF
(e) Subscription towards notified units of Mutual Funds
(f) ULIP of UTI
(g) National Saving Certificates,VIII Issue
(h) Deposit in a FDR for 5 years or more with a Scheduled Bank/Post Office in accordance with notified schemes
(i) Cont to notified Pension fund by Mutual fund or UTI
(j) Any other investment notified by the Central Government including Sukanya Samriddhi Scheme
4 Deduction u/s 80CCC Contribution to Pension Fund Scheme with LIC or other Insurer (Maximum Rs 1,50,000/- and the total deduction u/s 80C and 80CCC can’t
exceed Rs. 1.5 Lac.)
5 Deduction u/s 80CCD(1) Employee's contribution to National Pension Scheme:(upto 10% of salary and the total deduction u/s 80C ,80CCC and 80 CCD(1) can’t
exceed Rs. 1.5 Lac.)
6 Deduction u/s 80CCD(IB) Employee's contribution to National Pension Scheme:( maximum Rs 50,000/- in addition to the total deduction u/s 80C ,80CCC and 80
CCD(1) which can’t exceed Rs. 1.5 Lac.)
7 Deduction u/s 80CCG Investment in Rajiv Gandhi Equity Saving Scheme (RGESS)(deduction is allowed 50% on a maximum investment of Rs 50000/- to employees
having taxable income upto 12 lac. This is over and above the Rs. 1.5 lac deuction u/s 80C ,80CCC and 80 CCD. This deduction is allowed only for 3 consecutive
Assessment years beginning with the year first acquired.)

7 Deduction u/s 80D Medical Insurance (Premium shall be paid by Cheque/Credit Card only, deduction not allowed if paid in cash)
(a) Medical Insurance Premium paid for Self & Family ( Max. Rs 25,000, if >60 years: Rs. 30,000)
(b) Medical Insurance Premium paid for Parents ( Max. Rs 25,000, if >60 years: Rs. 30,000)
(c) Preventive health check ups (Max. Rs 5,000 for self, family and parents but within the overall limit stated above)
(d) Medical Expenditure in respect of Sr Citizen(80 yrs and above) if health insurance not paid (Max Rs 30,000 agt proofs of actual expenses incurred).

8 Deduction u/s 80DD Maintenance including medical treatment of a handicapped dependent who is a person with disability
(Please attach copy of certificate issued by specialist working in Government hospital for disability or mental retardation of dependent)
9 Deduction u/s 80DDB Medical Expenses incurred on treatment of a specified disease or ailment of self or dependents.
(Please attach copy of certificate issued in form 10-I by specialist working in Government hospital for disease.)
10 Deduction u/s 80E Interest on loan for higher education
A father can claim deduction if loan taken for kids study and interest there of is paid by him not by kids. In case of kids, deduction can be claimed if loan taken
for self study and interest is also paid by self not by father.
11 Deduction u/s 80U Deduction to a handicapped/disabled individual
(Please attach copy of certificate of disability or mental retardation issued by specialist working in Government hospital)
12 Income from previous employer
If you have joined LII during financial year 2015-16, please specify your income from previous employer in this financial year till you joined LII and attach 'proofs
(computation sheet) . In case no such income, please specity Nil.
13 Income from Any Other Sources
(a) Rental Income from House Property (if details about this house property is not covered at sr. no. 2 here above)
(b) Interest Income from Saving A/c or Recurring deposits (Interest income on Saving A/c or Recurring deposit wth Bank, post office or co-operative society
carrying banking business etc is exempted upto Rs 10,000 u/s 80TTA)
(c) Other Interest Income (i.e. interest on FDR and time deposits schemes with banks/post office/corporates)
(d) any other taxable income you wish to declare
14 In case of new joinee, the number of LTC exemptions availed during the current Block Years (i.e. 2014- 2017) from Previous employer.
I hereby declare that I will submit proofs of the above amounts in time as per company rules.

(Signature of employee)

F-128 : LII-LAAA00000-R-01136-128, R06 F-128_Income Tax Declaration Form Page 1 of 2

Additional Details for claiming Housing Loan Benefits or Housing Loan Benefits as well as HRA Exemptions
(Note: if you are claiming HRA exemption only, then this details is not required. For exact understanding of relevant provisions, please read 'Note on
Housing Loan Benefits or Housing Loan Benefits as well as HRA Exemption' attached herewith.)

Name of Employee: Date:

Empl. Code: DOJ:
Employee's Location(Gurgaon/Kolkata):

A Whether HRA exemption claimed (plz specify 'Y' for yes and 'N' for no) In proofs, duly singed original rent
receipts bearing revenue stamp and copy
if yes, plz specify : Complete Address of accomodation of PAN where applicable is to be
submitted
Rent paid/to be paid during the year
PAN of Owner, if rent paid is Rs 1,00,000/- PA or more(i.e. Rs. 8,333/-PM or more)
B Housing Properties and Housing Loans details:
Plz note that to avail housing loan repayment/interest benefits you shall be owner or co-owner of property and borrower or co-borrower in loan. Benefits
are allowed in proportion of your ownership subject to payments made by you for loan.
1 Number of House Properties you own (Plz tick 1, 2 or 3 as the case may be) 1 2 3
2 Propertywise details: 1st prop 2st prop 3rd prop
Type of Loan (Please specify 'C' if loan is for construction, 'P' if loan is for purchase of ready
house or 'R' if loan is for renovation/alterations)
Status of Construction/possession (In case of construction loan please specify 'Date of
Completion/Possession' if completed, else plz note that the benefits of housing loan
repayment/interest are not allowed during construction period)

3 Ownership detail (Plz specify 'S' for sole ownership & 'J' for Joint ownership)
4 City/place of property
5 Self occupied/ Let-out (Plz specify 'S' for self occupied u/s 23(2)(a), 'DS' for self occupied u/s
23(2)(b) 'L' for Let-out u/s 23(3), 'DL' Deemed Let-out u/s 23(4)(b)). if a perosn occupy two or
more properties, only one is allowed as self occupied and all other will be taxable as deemed
letout at prevailing rent.

6 If property is Let-out, please specify rental income (Plz note, It should not be less than the
reasonable expected rent of such property in same location. In case of Joint ownership,
please declare your part of income only)

7 If property is Deemed Let-out, please specify rent reasonable expected of such property in
same location.
8 Details of housing loan payments made by you (Considering the note highlighted above in
yellow color, housing loan benefits shall be availed in proportion of your ownership and
subject to loan payments made by you and please note deduction for repayment of principal
is not allowed in case loan is taken for renovation/alteration/ addition etc.)

I If construction/possession was completed prior to current F. Year 2015-16

a. Your portion of principal amount as per current year loan repayment certificate
b. Your portion of Interest amount as per current year Loan repayment certificate
c. 1/5th of the total interest paid till the Financial Year preceding to the Financial Year in
which construction completed/possession was taken. This deduction is available over 5
years beginning from the year in which construction/possession was completed.

II if construction/possession has competed during current F. Year(2015-16) and

i. If EMIs have started from the date of completion of constrution/possession:
a. Your portion of principal amount as per current year Loan repayment certificate
b. Your portion of Interest amount as per current year Loan repayment certificate
c. 1/5th of the total interest paid till last Financial Year (i.e. 2014-15). This 1/5th deduction
is available over 5 years beginning from FY 2015-16.

ii. If EMIs were started before completion of constrution/possession:

a. Your portion of principal repaid with effect from date of completion/possession.
b. Your Full portion of Interest amount as per current year Loan repayment certificate
c. 1/5th of the total interest paid till last Financial Year (i.e. 2014-15). This 1/5th deduction
is available over 5 years beginning from FY 2015-16.

Signature of employee
Note: Please attach provisional Housing loan Repayment Certificate.