Investment Declaration for the Financial Year 2011 -2012 (Apr 11 - Mar 12

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Investment Declaration Form: The Government of India permits tax benefit on investments in specified schemes. This form declares the investments you propose to do in the current financial year to avail of tax benefits. This form is to be filled up and sent to us before your first salary is processed, or else it will be considered that there are no Investments and Income tax will be deducted based on your income. Employees joining in between the financial year will have to give a declaration stating their earnings and deductions from 1st April till time of leaving immediate previous employment; else it will be considered that their previous income for the completed part of the year was same as their current income. Proofs of Investments have to be submitted to us by 15th Jan, else they will not be considered for Tax calculation. Emp. ID: _________________ ame : ___________________________________________________________________ N

PAN:

(PAN number is Mandatory. Non Submission of PAN will attract TDS @20% or Higher rate as applicable u/s206AA of Income Tax Act)

Amount (Rs.)
1 2 (a) 2 (b) 2 (c) Rent Mediclaim Premium for Self Mediclaim Premium for Parents Mediclaim Premium for Parents (Sr. Citizens) Rent paid during the period of employment with the company (for all the months, not just per month) Limit Rs.15,000/- per annum for self Limit Rs.15,000/- per annum for Parents who is below age of 60 yrs. Limit Rs.20,000/- per annum incase parents are senior citizens (Age 60 years and above)

Total eligible amt under Mediclaim prem. for Self (including spouse & children) is Rs.15000 & additional Rs. 15000 for Parents (in case Parents are Sr. Citizen eligible amt. is Rs. 20000 instead of Rs. 15000) (Attach Provisional Certificate Copy received from Institution) [If Loan availed on or after April 01, 3 Interest on housing loan 99 then Limit Rs.1,50,000/-, provided the acquisition is complete within 3 yrs from the end of the year in which capital borrowed] Repayment of Loan for 4 Limit Rs.40,000/- (Please attach Payment Receipts Copy received from Institution) Higher Education 5 a. b. c. d. e. f. g. h. 6 7 Deduction U/S 80C Life Insurance Premium Public Provident Fund NSC Accrued interest on NSC Maximum Limit Rs.1,00,000/- including PF Total Annual premium (excluding service tax, late payment charges, etc.) Limit of Rs.70,000/- per annum Investment in National Savings Certificate in the Name of Employee only is eligible. (Specify details)

Equity Linked Tax savings schemes Principal Repayment of housing loans Annuity / Pension plans Tuition fees paid for children - Only Tution fees amt. to be mentioned, Admission fees/Donation/development fees/Term fees/School Bus Fess etc. is not allowed Others Infrastructure bonds Any other amount eligible under S/ 80C of Income Tax Act. Investment in Specified Infrastructure Bonds - Maximum Limit Rs. 20,000/Please attach Provisional Certificate Copy received from Institution

Total Investments / Payments to be made in the Financial Year In case you were in employment for only part of the FY, Please check Y/N against the statements 1. I have not been in employment with any organization during the rest of the financial year. 2. Enclosed Form 12B as per the provisions laid down in Income Tax Act showing earnings from previous employer(s) from April 01 of the year till date of joining the Company during the Financial Year.

Y/N Y/N

I hereby declare that the above investment declaration given by me to the company is true, correct and genuine to the best of my knowledge. In the event of the said investments not done on or before Jan 15th of the Finacial Year, I would be solely responsible for any tax/ interest/ penalty liability and I agree to pay the cost/ expenses incurred by the company even in the event of discontination of services of the company.

Place Date
For PAYROLL USE ONLY Checked by (Name):

Employee’s Signature: ___________________ Employee’s ID: ___________________
Entered by Accounts / HR (Name):

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