Declaration for payments due after proof-

submission deadline
Emp Code:

Name:

Given below are the details of premiums that are due for payment after the proof cut-off date but are payable before the
end of the financial year 2022-2023. Please consider these premiums payable for the tax benefit in the current financial
year 2022-2023.

Sl. No. Month Due Date Monthly Amount

House Rent payment/ HRA 1
2
3

Sl. No. Policy No Due Date Amount

80CCC Pension Policy 1
2

Sl. No. Policy No Due Date Amount

Unit Linked insurance plan 1
2

Sl. No. Policy No Due Date Amount

1
2
Life insurance Premium
3
4
5

Sl. No. Name of the Fund Due Date Amount

ELSS 1
2

Note: Benefit will be extended only on submission of this form for any premiums falling due after the proof cutoff date.
Plans to take a new policy after proof cut-off date will not be considered.

© 2022 Wells Fargo Bank, N.A. All rights reserved.

 Employee Declaration

I hereby 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 payments before March 31, 2023.

Date: Signature