Employees Provisional Savings (EPS) form for Calculation of TDS to be deducted for the Financial Year

2021-2022

Name of the Employee: Employee ID:

PAN of the Employee : Mobile No:

Email Id (for sending Form 16 & Pay Slips):

Date of Appointment: (Applicable for New Joining made after 01/04/21)

Sl. no Particulars Amount

1 House Rent Allowance

(i) Rent Paid to Landlord Rs.

(ii) Name of the Landlord:

(iii) Address of the Landlord:

(iv) PAN of the Landlord:

Note:PAN shall be furnished if the aggregate rent paid during the year exceeds Rs. 1,00,000/-

2 Leave Travel Concessions (Allowed only if claim is not made two times from 2018-2021) Rs.

*One Round trip per year and the travel must be with in India for the period 01-01-20 to 31-12-21

Note: If Travel by Air - * Boarding Passes are mandatory to claim the re-imbursment of LTA

If travel by Car - * Travels Bills & Toll Charegs are mandatory to claim LTA

3 Deduction of Interest on Housing Loan (Please fill the annexure for House property) Rs.

4 Any other Income Reported (Detailed information to be given) Rs.

6 Deductions U/S 80 (C ) Savings

a) Life Insurance Policies (LIC) Rs.
Note: 10% of Sum Insured or Premium which ever is less will be allowed as deduction if the Policy is taken after

01/04/2012 & 15% of Sum Insured or Premium paid which ever is less is allowed in case of Policy taken on

Dependent person who is suffering with disability defined U/s 80DDB)

b) Unit Link Insurance Policies (ULIP) Rs.

c) Public Provident Fund Rs.
d) Housing Loan Principal Repayment Rs.
e) Children Education Fee Paid to approved Institution/University/Collage with in India Rs.
(I) Child 1 – Rs.
(II) Child 2 – Rs.
f) Amount Deposited in Sukanya Samridhi Account in the name of Girl Child Rs.
g) Mutual Funds (ELSS Schemes only) Rs.
h) Any Amount deposited in a Fixed Deposit of any Bank under IT Scheme Rs.
I) National Saving Certificates (NSC) Rs.
j) Interest on National Savings Certificates (NSC) Rs.
k) Infrastructure Bonds Rs.

6 Contributions made to “NATIONAL PENTION FUND” U/S 80CCD (1B) Rs.

Maximum of Rs. 50,000/- or paid amount which ever is less will be allowed as deduction
 (Page- 2)
Sl. no Particulars Amount

7 Medical Insurance Premium and Preventive Health Checkup Expenditure U/S 80D

a) Self and Family Rs.

b) Parents Rs.

Note: (Maximum of Rs. 25,000/- paid by way other than Cash towards Medical Insurance Premium will be allowed as deduction

U/s 80D and an additional Rs. 25,000/- premium paid will be allowed if an additional policy taken on Parents whether they are depended

or not on the assessee. In case of Senior Citizens Rs. 50,000/- will be Replaced in place of Rs. 25,000/-)

8 Deduction in respect of “Interest on loan taken for higher Education“ U/S 80 E Rs.

Payment made towards Interest is allowed as deduction

9 Deduction in respect of Maintenance including “Medical Treatment” of a Handicapped Dependent Rs.

Who is person with Disability as defined U/S 80DD will be allowed by furnish a copy of the certificate issued by the medical Authority

( A Maximum of Rs. 75,000/- will be allowed with General Disability. In Case of Severe Disability Rs 1,25,000/-)

10 Deduction in respect of Medical Treatment U/S 80DDB (Shall have to submit a Doctor's Prescription having a Degree) Rs.

(Rs. 40,000/- or the amount actually spend will be allowed as deduction. If the dependent is a senior Citizen then the Deduction

will be Rs. 60000/- or amount spend which ever is less will be allowed as Deduction)

11 Deduction in case of a “Person with disability” U/S 80U Rs.

(will be allowed by production of Form 10-I issued in the year 2021-22 for a fixed Deduction of Rs.75,000/- .

In Case of Severe Disability Rs. 1,25,000/-.

DECLARATION

I …...............…..………………………………………………. S/o/D/o …….......…………………………………………. Do here by solemnly affirm and declare that to the best of my

knowledge and belief that the information provided in this form and its accompanying annexure's are true and correct and nothing material is concealed there from.

I also undertake to indemnify the company for any loss/liability that may arise in the event of the above information being incorrect .

Place:

Date: (Signature of the Employee)

 Details of House Property Income
Computation of Loss/Profit from House Property
(Please Fill Up all the Columns)

1 Name of the Employee: _______________________________

2 Address of the Property on which Interest and Principle are claiming as deductions

________________________________________________________________________

3 Self Occupied

Date of Loan borrowed ________________

Date of acquisition/Completion of Construction ________________

Date of occupation ________________

Interest paid during period April '21 to March '22 Rs.

(Please Enclose the Provisional /Certificate Issued by
the Bank / Financial Institution)

4 Computation of Loss from House Property (RENTED OUT)

Name of the Tenant* _______________

Rental Income Rs.

Less: Municipal Tax paid Rs.
Total Rs.

Less: 30% for Repairs & Maintenance Rs.

Net Annual Value Rs.

Less: Interest paid on borrowed Loan Rs.

1/5th of Pre–Construction Interest (if any) Rs.

Net Income/(Loss) from House Property Rs.

(Maximum of Rs 2,00,000/- only)

I hereby certify that the above information is true and correct

(Signature of the Employee)

Please use separate sheet fro each property