DECLARATION

I, ___ ________________ hereby declare that the premium for the life insurance
policies/ELSS/SIP taken by me is due as under

Details of Insurance Policy

Premium Monthly / Qrtly / Half

S No. Policy Number Due date
Amount Yearly / Yearly
1.
2.
3.
4.

Details of ELSS/ SIP

Premium Monthly / Qrtly /
S No. Scheme Due date
Amount Half Yearly / Yearly
1.
2.
3.
4.

I confirm that the above premiums/ELSS/SIP will be paid by me on or before the due
dates before the end of the financial year nd I shall produce the copy of the premium
paid receipts/proof payments for verification as and when required by the payroll
department of the Company or by the Income Tax authorities.

Request the Company to consider this declaration for the purpose of computing my
tax liability for the financial year. I agree to indemnify the Company for any loss
arising on my failure to act as per this Declaration.

I am also attaching a copy of the last year payment receipt or payments done till date
as a proof of the investments