Self-Declaration for the financial year ending 31st March 2022

(For claiming exemption for House Rent Allowance in case you stay in a city other than work city)

Employee Name ABC

Employee SID A123456

Address of the Property taken on

XYZ
rent :

Employee PAN ABCDE1234F 10 Character – Alpha Numeric

I, ABC working / worked in the company with

SID A123456 hereby confirm that my official work location is in
However, due to COVID-19, I am staying in a residential accommodation (address as mentioned above)
taken on rent by me for the period DD-MM-YYYY to DD-MM-YYYY

I hereby declare that the above mentioned information is true and I am fully aware of the said
provisions of the Income Tax Act, 1961 to avail the exemption/ deduction benefit. I will be solely
and wholly responsible to handle any queries from any competent officials and / or to submit all
relevant documents to the Income Tax / Competent Authorities. .

Date: DD-MM-YYYY
Place: MUMBAI
ch 2022
city other than work city)

ked in the company with

GHI
oned above)
DD-MM-YYYY

ully aware of the said

benefit. I will be solely
s and / or to submit all
.