INCOME TAX SAVINGS DECLARATION FORM FOR F.

Y 2010 - 11

Name of the Employee :

Designation :
Father Name :
PAN Number :

Sl No Particulars Amount(Rs.)
1 Contribution to PF
2 Fixed Deposits not less than 5 Years
3 Housing loan - Interest (U/S 24)
4 Housing loan - Principal
5 Investment in Approved Mutual Funds
6 Investment in P.P.F
7 Investments in NSC Bonds
8 Life Insurance Paid
9 Medical Insurance Premium
10 Post Office Savings not less than 5 Years
11 Rent Paid per month
Tuition fees Paid
12
[Only Tuition Fee excluding development fees, donation,etc)

13 Others (Please Specify)

TOTAL

I hereby confirm that I am paying a sum of Rs.___________ per month from___________(DD-MM-YY)

as house rent for accommodation occupied by me at _______________________________________
_________________________________________________________________________ (Address)
and therefor would like to claim tax benefit under section 10(13A). I have attached the evidence of
actual payments of rent by giving details of rent paid along with name and addess of the Lanlord.

I am aware that payments on account of above investments are eligible for rebate under the relevant

sections of the Income Tax Act, only when payments are made out of my income chargeable to tax.
I declare and undertake that such payments have been made and/or will be made out of my Income.
I declare that to the best of my knowledge and belief, the particulars furnished by me are true and
correct.

(Signature)

Note :
1 Xerox copy of above declared details to be submitted.
2 Original rent paid acknowledgement (bill or receipt) required for rental payment.
(revenue stamp to be affixed & signed by landlord)
3 Pan No of Landlord is must if rent is above Rs.15,000/- per month