Company Name: * Employee Proof Submission Form (EPSF) 2011-2012 Please read the instructions attached carefully before

filling up the form THE LAST DATE FOR SUBMITTING PROOFS IS: Employee Name * Address for the purpose of HRA*

Employee ID * Gender 10-Feb-2012 No of Children going to school*

Emp PAN No.* Sl. No A

Loss from House property

Item
Self Occupied

Date of Joining* As Per last Declaration (Rs.)

Value of Proof attached (Rs.)

Approved amount (To be filled by TL)

(Attach form 12C) Let Out (Income form House Property to be shown in B) (Incase of joint loan A/C mandatorily specify your Share other wise proof will be rejected.)*

B C

Other income Reported (Attach From 12C) Deduction Under Chapter VI A 1 Sec 80D - Medical Insurance Premium 2 Sec 80DD Medical treatment/insurance of handicapped dependent 3 Sec 80DDB Medical treatment (specified diseases) 4 Sec 80E Repayment of Interest on Loan for higher education (only interest is exempted) 5 Sec 80U Physical Disability D Investment u/s 80C capped @ 1 Lac, In case of any investment under S. No 15, the cap is increased to 1.2 lacs 1 PF contribution (including VPF) deducted through Payroll XXXXXXXXXXXXXX XXXXXXXXXXXXXX 2 Life Insurance Premium Deducted through Payroll XXXXXXXXXXXXXX XXXXXXXXXXXXXX 3 Public Provident Fund 4 Life Insurance Premium 5 Deposit In NSC 6 Interest on NSC reinvested 7 Principal Loan (Housing Loan) Repayment 8 Registration/Stamp Duty charges paid for registration of HP 9 Mutual Funds 10 ULIP of UTI/LIC 11 Children Education Tuition Fees 12 Post office Time Deposit 13 NHB Scheme 14 Fixed Deposits with Schedule Bank 15 Infrastructure Bonds (Rs.20,000/- Extra Exemption if invested in Infrastructure Bonds only) 16 Contribution to Pension Fund E Exemptions Under Section 10 & Equivalent 1 Medical Reimbursement 2 LTA Control Total (Please total the figures entered as a control check)[Mandatory] Value of Proof attached (Rs.) F From Date To Date Rent P.M. 1 HRA DECLARED 2 HOUSE RENT 3 HOUSE RENT 4 HOUSE RENT 5 HOUSE RENT Previous Employment Salary Salary earned from 01-APR-2011 till date of joining (Applicable only if joined after 01-APR-2011) PARTICULARS 1. FORM 16 YES / NO Rs. 2. FORM 12BA YES / NO Rs. 1) I hereby declare that the information given above is correct and true in all respects. 2) I also undertake to indemnify the company for any loss/liability that may arise in the event of the above information being incorrect. *Indicated mandatory fields with information as per our database. Please verify the same and if blank, please fill and submit this form. Date: Place: Signature of the Employee*