INCOME TAX EXEMPTION / DEDUCTION FORM Financial Year

20___to 20___
Please submit tax proof for current financial year claiming Income Tax exemption / deduction
Employee Name : Employee No :
Gender : Permt. Acct No. (PAN) :
Location / Entity : Date of Joining :
Cell / landline No. Email:
A. Details of Rent paid for claiming HRA exemption (Section 10(13A))
S. Period of rented accommodation (DDMMYY to Receipt attached Monthly rent Total Rent
No. DDMMYY) Yes/No payable during
the FY

B. Deductions u/s 80 C. (Maximum Exemption Rs. 100000)

Life Insurance Premium paid by you directly on the insurance of Life of Self/Wife/Children Amount p.a.
1 will qualify for income tax rebate as details given below: (Rs.)
Insurance For whom (Self Insurance
S.No. Policy No. MLY/HLY/YLY
Covered /wife/Children Premium paid
i
ii
iii
iv
v
Please submit separate sheet in above format for more line items of Insurance Prem.

2 Contribution to Pension Fund (Annuity) - Sec 80CCC

3 Unit Linked Insurance Plan (ULIP)

4 Equity Linked Saving Scheme (ELSS)

5 Public Provident Fund (PPF) (Max. Rs.70,000/-p.a. may be invested)

6 Investments in Term Deposits (Period of 5 yrs or more) in a Scheduled Bank

Housing Loan - Principal Repayment /and payment towards stamp duty/registration fee towards cost
7 of residential property purchased

8 Mutual Funds – Tax Saver

9 Infrastructure Bonds (period of not less than 3 years in a notified Public Company) -10(23D)

10 Tuition Fee (Education Fee or School Fee)

11 Purchase of NSC VIII Issue

Accrued Interest on NSC (will be included in Other Income)- Pl furnish details in the format given in
12 next sheet

13 Post Office saving Scheme

14 Others…………
C. Income / Loss from House Property
Interest benefit of Housing Loan [Profit or Loss from Residential House Property]
15 Please attach statement of Profit / Loss from house property
D. Deductions Under Chapter VI A

Sec 80D - Medical Insurance Premium: (Amount eligible upto Rs. 15,000)
for Senior Citizen (age 65 and above) - exemption is upto Rs. 20000 (Payment made by cash will not
16 qualify for exemption)

17 Sec 80DD - Medical treatment / Insurance of handicapped dependant (Attach form 10 IA)

18 Sec 80E - Repayment of Loan Interest for higher education (only Interest)

19 Sec 80U-Handicapped Individuals (Attach form 10 IA)

 20 Education Allowance 10 (14) - (max of 2 children @ Rs.1,200.00 per annum per child)
Control Total (Total the figures entered in A+B+C+D)

DECLARATION:
I confirm that the above statements are true to the best of my knowledge and all the copies of the rent receipt / investment proofs
have been attached along with this form. I am responsible for any tax calculation / tax deducted on the basis of the above
statement and proofs submitted. I also confirm that I shall furnish any additional (adequate) supporting to the company as & when
asked, failing which company is authorised to disregard the above as a basis for any tax calculation done.

Signature of Employee
Date: 15-Aug-15
 Details of Accrued Interest on NSC, if any

Amount of Interest
Certificate no. Month & Year of purchase Amount (Rs.) Completed Years (Rs.)

Total 0.00

I …………………………hereby certify that above interest has been computed in accordance with
the provisions as laid down under Chapter VI A of Income Tax Act

Place:
Date
Signature of the employee
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 GUIDELINE FOR SUBMISSION DOCUMENTS NOT ACCEPTABLE Forms

A) HOUSE RENT ALLOWANCE [RENT RECEIPT]

Pl attach original (or self certified) monthly rent paid receipt for the current financial year Rent receipt for the last financial year will not be accepted

Please ensure that RENT RECEIPT should have following details:

- Receipt no. & date, Monthly amount of RENT paid, rent for the month of, Address of the rented property, Name, address of property owner. The rent receipt may also
include PAN of the landlord, if available to the employee.

Please affix Revenue Stamp (if applicable as per State legislation)

B) LIFE INSURANCE PREMIUM (80C)

The benefit may be availed for SELF or SPOUSE or CHILDRENS if payment has been by the Insurance Premium in excess of 20% of sum assured will not qualify for
employee during the financial year exemption
Please clearly mention policy no., pay frequency, relationship and annual amount Proposal receipt is not accepted

In case premium is not due at the time of submission of tax proof, please submit copy last paid Last to last year paid receipt will not be accepted for benefit in the
premium receipt current financial year
C) UNIT LINKED INVESTMENT PLAN / PENSION PLAN / ELSS (80C)

The benefit may be availed for SELF or SPOUSE or CHILDRENS if payment has been by the
employee during the financial year

In case premium is not due at the time of submission of tax proof, please submit copy last paid Last to last year paid receipt will not be accepted for benefit in the
premium receipt current financial year
D) PUBLIC PROVIDENT FUND (PPF) (80C)

The benefit may be availed for SELF or SPOUSE or CHILDRENS if payment has been by the
employee during the financial year. The maximum amount can be invested is Rs.70,000/- p.a. in
any financial year Proposed or Last year paid receipt will not be accepted
Please submit copy of challan / Pass Book issued
E) TAX SAVING TERM DEPOSIT WITH SCHEDULE BANK (5 YEARS OR MORE)

The benefit may be availed for SELF or SPOUSE or CHILDRENS if payment has been by the
employee during the financial year Proposed or Last year paid receipt will not be accepted

Please submit copy of investment made during the current financial year in Tax Saving Term
Deposit
F) BENEFIT OF INTEREST ON HOUSING LOAN & PRINCIPAL
Please submit the computation of Loss or Profit from house property in the format attached in Col. E
Please submit copy of banker provisional certificate for repayment of Principal & Interest for the current financial year
Employee availing benefit first time is also required to submit copies of possession letter and ownership documents

In case of jointly acquired property, please submit the declaration for the current financial year. The format of the declaration has been in given in second sheet of the
file attached at Col. E.
G) TUITION FEE (80C)

Only Tuition Fee is allowed for exemption u/s 80C No Computer Fee / Transport /Building is allowable for exemption

Please submit receipt for the current financial year

H) MEDICAL INSURANCE (80D)

Deduction available in case mediclaim Insurance availed from outside Siemens. Copy of Premium
paid receipt for current Financial Year is required.Policy may be in the name of self, spouse & Exemption would not be provided, if the payment is made through
children or dependant parents Cash
I) INTEREST BENEFIT OF EDUCATION LOAN (80E)

Loan taken for full time higher studies, should be in the name of the assessee. The benefit will be available only for Interest paid during the financial year. The deduction
will available for a max period of 8 years or till the interest is paid , whichever is earlier.
Please submit banker's certificate for the current financial year
K) DEDUCTION IN CASE OF DISABILITY -SELF (80U) / MEDICAL TREATMENT ON HANDICAPPED DEPENDENTS (80DD)
Eligibility: Self, Spouse, Children, Parents, Brothers and Sisters
Photocopy of certificate issued by Government medical authority (Form 10IA)
Receipt of the amount paid to LIC for the policy cannot claim both 80U and 80DD
Exemption for Professional Tax is also available in case of Permanent disability
L) EXEMPTION FOR EDUCATIONAL ALLOWANCE FOR CHILDRENS (10 (14))

Child Education: Exemption available for Rs.100/- p.m. per child, max upto two children.

Pl attach a copy of paid receipt for the current financial year

M) EXEMPTION FOR MEDICAL ALLOWANCE

Original medical bills for the current Financial Year are required to be submitted Cosmetic/Consumer/toiletries/Health Drinks/goggles not considered
N) LTA EXEMPTION FORM
Please refer to the guidelines given in the LTA Exemption Form Incomplete form will not be accepted for LTA exemption

In block of four year (01.01.2006 to 31.12.2009) two LTA (journeys) are taxable and two are
exempted. Please tick appropriately
O) RCARE EXEMPTION FORM

Employees who have Car under the scheme will submit a the attached form along with necessary
supporting bills / receipts Without attaching any proofs, RCARE exemption will not be granted

Pl ensure all the expenses should have been incurred during the current financial year
 GUIDELINE FOR SUBMISSION DOCUMENTS NOT ACCEPTABLE Forms
Q) INCOME OF PREVIOUS EMPLOYER IN FORM 12B
Employees who have joined during the current financial year may submit their income &
details of tax deducted in the attached in Form 12B along. In case tax has been
deducted during the year, pleaes enslose a certificate issued under section 203.

Note: Employees may submit any additional investment made during the financial year. They are required to give details of additional investments in a appropriate form. The details of
investments already given need not required to be mentioned in the form again. After 15th March, no tax proofs will be considered for that financial year.