Future Payment Self Declaration for the Financial Year 2021-22

Company:
Emp. No.
Name:
Location:

House Rent payable after the Investment proof submission cut off date
Sl No. Rent for the month Monthly Rent
1 Dec-21
2 Jan-22
3 Feb-22
4 Mar-22
Total -
This to confirm that I would be paying rent sum of Rs. - for the period
from to

The proofs / original rent receipts would be submitted on request

Signature: ___________________________________________
Name: 0
Insurance Permium U/s 80C Premium payable after the Investment Proof submission cut off date)
Name of the Policy Insurance Due for the Relationship to
Sl No. Policy No. Holder Company Mode month Amount Employee
1
2
3
4
5
6
7
Total -
This is to confirm that insurance permium payable sum of Rupees - after the Investment
Proof submission cut off date would be paid by me before 31 of Mar 2022.
Permium paid receipts would be submitted on request.
Any other investemnts - Please provide the details below

Nature of Investment Due for the Relationship to

Sl No. Payment Name Company Mode month Amount Employee
1
2
3
4
I hereby certify that the tax benefits arising on the above payment / Investment shall be made by end of March 31st,
2022 and request you to kindly consider the same for computing my tax liability for the financial year Apr 2021 – Mar
2022.
Further, I hereby certify that the tax benefits arising on the above payment / Investment have been claimed only by me
and not by any of my dependents.
I hereby absolve the Company from any tax or other liability that may arise on this account.
I hereby certify that the above information is true and correct.
Note : Future investment declaration will not be considered without last year paid document proof.
Signature: __________________________________
Name: 0