SAVINGS DECLARATION (OTHER THAN THROUGH SALARY)

FINANCIAL YEAR 2020-21(ASS.YEAR 2021-22)

PL.NO. NAME: CORPORATE ID:

PAN NO. MOB.NO.

1 Savings under Sec. 80 C

Code No. Short Name Particulars of savings Please attach
227 LIC Life Insurance Premium Photo copy of receipt
809 PPF Public Provident Fund Photo copy of passbook
807 NSC NSC VIII Issue purchased during the year Photo copy of certificate
805 ULIP ULIP of UTI/LIC Mutual Fund ( DhanRaksha) Photo copy of receipt
814 TUITION TuitionFee(exceptdevelopmentfee/donation)paidtoeducational
institution Photo copy of receipt

815 Annuity Annual Plan of LIC(JiwanDhara/Akshay/ICICI Prudential Life

Photo copy of receipt
Insurance/Tata AIG
816 FD Fixed/Time deposit of 5 yrs or more in Bank/ Post Office Photo copy of receipt
806 RBS RetirementbenefitUnitSchemeofUTI/KothariPioneerPension
Plan Photo copy of receipt

810 MF EquityLinkedSavingsScheme(UnitsofMutualFundspecifiedu/s
Photo copy of receipt
10/23D)
211 HBA Repayment of House Building Loan Certificate from Bank
811 HL A/C Subscription to Home Loan Account Photo copy of passbook
818 NPS National Pension Fund Photo copy of the Certificate

Please fill up the code no., short name, savings particulars in this format
CodeNo. Short Name Policy/Receipt/Certificate/Account/ Date of deposit Amount deposited(Rs.)
Membership No.

2. Pension Fund of LIC/SBILife/ICICI Prudential Plan (80CCC)-Code801

Sl.No. Name of the Plan Policy/Receipt No. Date of deposit Amount deposited(Rs.)

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3. Medical/Health Insurance Primium(Mediclaim)U/sSec.80DCode817
Sl.No. Policy No. Sum Assured Date of deposit Amount deposited

4. Physically handicapped(dependantu/s80DDcode803/selfu/s80UCode802)
Name of the person Relationship % age of disability Amount(Rs.)

5. Medical Treatment(Selfordependent)(Neurology/Oncology/Hematologyetc.)U/s80DDB
Name of the dependant Disease Receipt No. & Date Amount incurred

6. Interest on Loan taken for higher education of son/daughterSec.80ECode813

Name of the child Course detail Name of the Institution Amount (Rs.)

7. Payment to House Rent for exemption of HRA(Receipt to be enclosed)

Name and address of the Landlord (with his PAN No. if Monthly Rent Date of payment Amount (Rs.)
annual rent exceeds Rs. one lakh) paid

8. Details of income from other than salary

Monthly Pension received from Amount (Rs.) Bank Interest from Savings Bank Amount (Rs.)
Govt./EPS'95 A/c in excessofRs.10,000/-per
annum

9. Employees Contribution under NPS U/s 80CCD(1B) (Max Rs 50,000/-) Code …..
Sl.No. Permanent Retirement Account Number NPS Receipt No. Date of Amount deposited
(PRAN) deposit (Rs.)

DECLARATION
I hereby certify that the above particulars are true to the best of my knowledge and belief
and any change during the financial year after the date of submission of this declaration will be
intimated in due time.I also certify that the savings declared are from my income received during
the year.

( Signature of the employee )

Note: Photocopies of all the documents duly signed pertaining to the above must been closed.

Date:
Enclosure:
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 Declaration by the employee for claiming deduction under Sec.24(b)of IncomeTax Act,1961
Income from House Property/Set off of Losses on House Property for the
Fin.Year2020-2021 (Ass.Year2021-22)

Name and address of the Institution

from where House Building Loan
taken:
Amount of Loan taken prior to 01.04.1999: Amount of Loan taken on or after 01.04.1999:

Particulars Property - 1 Property - 2

Full address of the House Property

(Enclose the Completion/Possession
Certificate )

Whether Self Occupied or Let Out

If Let out, Annual Value of the property

IfLetout,MunicipalTaxesPaid(Enclosethe
receipt)

Interest on Borrowed Capital(Enclose the

certificate from the Bank/Institution)

1. Attach photocopy of completion/possession certificate for claim of deduction of interest on borrowed capital against
income from House property.
2. AnnualValueofSelfOccupiedPropertyistakentobeNil.

3. Annual Value of property deemed to be let out is Reasonable expectedrent (fair value or expected rent)or rent actually
received whichever is higher.

4. If more than two houses please attach separate

sheet.
DECLARATION

I hereby certify that the above particulars are true to the best of my knowledge and belief and any
change during the financial year after the date of submission of this declaration will be intimated in due
time.

Date: (Signature of the Employee)

Enclosure:

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