FORM A (Declaration)

STATEMENT OF PARTICULARS FOR TAX DEDUCTION AT SOURCE FOR

THE FINANCIAL YEAR (Salary) APRIL 2024 TO MARCH 2025

S.No. Particulars Details

1. Name of the Employee

2. Department H.Q

3. Pan Number
4. Residential Address

5. Are you filing your return of Income

6. Total Rent Paid/Payable by you during the

year April 2024 to March 2025
7. Date of joining

(8. Taxable Salary Received from the previous

employer
9. Copy of Form 16 issued by previous
employer
10 Leave Travel Allowance (LTA) (Ticket for
proof of travel)
11 Total Investment :
L.I.C
12 Mediclaim :
13 Mutual fund :

14 Other Insurance :

15 Education Fees for Children :

16 ICICI Prudential pension fund :

17 Any other investment : PPF

18 Repayment of Education Loan for self Principal Amount Interest Amount

19. Repayment of Housing Loan Principal Amount Interest Amount

20 Select Tax Regime Old Regime New Regime

I hereby authorize you to deduct tax at source on income received /accrued to me as declared above.

I hereby confirm that the particulars /information given above are true and correct to the best of my
knowledge. I further undertake to produce evidence in support of the above statements as and when
called upon to do so by you or by Income Tax Authorities.

Date: Signature:
Place: Name:

** Tax will be calculated based on the information provided by you in the above
statement. If any, tax is due which will be deducted in equal installments from Salary.

All copy of investments/Savings should be mailed by 20th April 2024 at

deepak@shreepushkar.com