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General Details
Name (as appearing in Equant technology services IndiaPPvt
V Srikanth
Ltd. ESS)
Employee ID 9000746
Contact Number (Extn. & mobile) 99625 83436 / 6649 6703
Income Tax Permanent Account Number (PAN) -

If PAN not applied, please apply immediately and provide proof of acknowledgment or else your investment submissions will not be considered

Previous Employment details (If joined ETSIPL after 1st April 2011)
Employer Name
Date of relieving [ DD - MMM -YYYY ]

Previous Employer Declaration attached

The Income Tax Computation for the financial year 2011-12 will be reckoned and determined
considering the income earned in Equant technology services India Pvt Ltd. only. The
If Copy of statement of income or Form 16 from
responsibility of clubbing the income lies with you and the resultant tax if any has to be paid
previous employer is not attached, this will result in --->
at the time of filing your individual income tax return along with any penalty or interest, if
any, for late payment of taxes.

The Finance Department,
Equant technology services India Pvt Ltd.
Vashi, Vishwaroop IT Park.

Please find below the details of expenditures/investments for the financial year 2011-12 for tax purposes.
Copies of the necessary documents are attached herewith.

Note: All expenses / investments should have been incurred / invested during the period 01-Apr-11 to 31-Mar-12.

EXEMPTION / REBATES Proof of expenditure to be submitted (Rs.)

Original Rent receipt for all the months or a

consolidated receipt. The receipt should clearly
House Rent From April/11 To March/12 state the amount and period for which house rent 108,000.00
has been paid. The address of the owner of the
house must be mentioned on the receipt (s).

Refer to Investment Declaration Guidelines.

Medical Insurance Premium [ Section 80 D ] - sum paid to effect or to keep in force an insurance on the health
Payment made by Equant technology services India
of the employee,spouse,children or dependent parents.
Pvt Ltd. towards employee mediclaim policy is a
benefit and hence not eligible for deduction.

Original certificate issued by the designated medical

Medical expenses for handicapped dependents [ Section 80 DD ] authority along with self-declaration for amount
spent on treatment of handicapped dependant.

Medical expenses for specified diseases [ Section 80 DDB ] Refer to Investment Declaration Guidelines

Higher Education Loan Repayment-Interest Only [ Section 80 E ] Refer to Investment Declaration Guidelines

Deduction for employee with disability [ Section 80 U ] Refer to Investment Declaration Guidelines

Housing Loan Interest Component on Self occupied property [ Sec 24 ] Refer to Investment Declaration Guidelines

Others [ Please specify ]

TOTAL [A] 108,000.00

EXEMPTIONS / REBATES Proof of expenditure to be submitted (Rs.)
Life Insurance Pension Scheme [ Section 80 CCC ]
Policy No Date of payment Premium (Rs.) Copies of premium paid receipts for the F.Y. 2011-
0 12. Late payment fees will not be considered

Subscription to Public Provident Fund [ Section 80C ] - in name of employee, spouse and children Refer to Investment Declaration Guidelines

National Savings Certificate- or Postal Deposits [ Section 80C ] Refer to Investment Declaration Guidelines

Life Insurance Policy [ Section 80C ] - in the name of employee, spouse and children
Policy No Date of payment Premium (P.A)
LIC June-11 10,000.00
TATA AIG September-11 20,000.00 Copies of premium receipts paid during the F.Y.
LIC August-11 30,000.00 2011-12.
0.00 0.00
0.00 0.00

Children's Education [ Tuition Fees only-Sec 80C ] Refer to Investment Declaration Guidelines

Housing Loan Principal Repayment [ Section 80C ] Refer to Investment Declaration Guidelines

ELSS Mutual Funds,ULIP etc [ Section 80C ] Copies of Payment Receipts.

Fixed Deposit with Scheduled Banks- long term over 5 years Copy of Deposit receipt/ Certificate issued

Infrastructure Bonds [ Section 80C ] Copies of Bond certificates or payment receipts.

Others [ Please specify ]

TOTAL [B] 50,000.00

I hereby declare that

(a) The Expenditures declared and Investments made have been or will be made for self and/or dependants only.
(b) I fully understand that in case I am unable to do so & submit the proofs by 10-Jan-2012, the resultant tax will be recovered from me. Further I shall be
solely responsible for any consequent penalty & interest.

Thanking you

Yours truly

Employee Signature

Employee Name

Declaration Form

For Claiming Deductions under Sec 24 (Housing Loan interest on self occupied property)

I, _______________________ (name of employee) residing at (address) ____________________________________

__________________________________________ declare that I have paid Rs._____________( Rupees
__________________________________________ ___________________________________ __________________________) towards interest for the
period From ___________ To for housing loan taken from ___________
__________________________________________________________________(Name of the Financial Institution) The house has been fully
constructed/purchased on (date)___________ for my self occupation only and I do not derive any income during the financial year 2011-2012 from the said
house. I have enclosed a copy of Banker's Certificate for the interest paid. I also declare that I have taken this loan on ____________ (specify the date).

I furthure declare that the Property is owned by myself or I am the coowner and my % of sharing as cowner is _____ (strike off which is NA). I am
paying the EMI in whole or Rs _____ of the total EMI and the balance is paid by the other coowner.
I furthure declare that by 10th April-2012 I will submit the actual Housing laon certifcate agaisnt the provisional one which I have submitted now.

Address of the House:


Declaration for the House Rent payable for the month of Jan, Feb & Mar 2012

I hereby declare that I will be paying Rs.1,08,000(Rupees One Lakh Eight Thousand Only) towards my House Rent for the month of Jan, Feb & Mar 2012 in
addition to the house rent shown in the above receipt (s).

Signature of the employee

Given below are the details of premiums that are due for payment after the proof cut off date, but are payable
before the financial year-end 2011-12. Please consider these premiums payable for the tax benefit in the current financial 2011-2012.

Sl No Insurance Policy Policy No Due Date Amount

Sl No Mutual Fund-Scheme Account/Folio No Due Date Amount

Employee Declaration
I here by declare that the information provided above is true and correct and will be solely responsible for any situation arising out of
non-payment of the above premiums before 31st Mar 2012.
Form for sending particulars of Any Other Income under section 192(2B) for the year ending March 31, 2012

1. Name and address of the employee

2. Permanent Account Number
3. Residential Status
4. Particulars of income under any head of income other than “salaries”(not
being a loss under any such head other than the loss under the head
“Income from house property”) received in the financial year –
(i) Income from house property (in case of loss, enclose computation thereof)
(ii) Profits & gains of business or profession
(iii) Capital gains
(iv) Income from other sources:
(a) Dividends
(b) Interest
(c) Other incomes(specify)
5. Aggregate of sub-items (i) to (iv) of item 4
6. Tax deducted at source (enclose certificates) issued u/s.203

Declaration for the vehicle under Flexi benefit Plan.

I hereby declare that I am owning the Vehicle in my name. The details of the Vehicle are attached herewith. I Further declare that if there are any changes
related to vehicle I shall keep company informed of the same. I am also attaching RC copy with this.

Vehicle No :
Car Model :
Cubic Capacity :
Signature of the employee


I,…………………………… hereby declare that what is stated above is true to the best of my knowledge and belief.


Signature of the employee