Declaration by the employee for Final computation of Income Tax under the provisions

of Income Tax Act, 1961 for the financial year 2011-12

I, (Name) _____________________(Emp.Code) ______________ declare that I have

paid/deposited Rs.________ for Medical treatment of____________________(name of patient)
who is suffering from_________________ (specified disease name) and he/she is my
___________ (relationship).

I, further declare that the information given above is true and correct to the best of my knowledge.

Date :_______________________ Signature :__________________________

Enclose: Form 10-I (issued by prescribed authority)