INCOME TAX DECLARATION FORM FOR 2011-2012 ( To be used to declare investment for Income Tax that will be made

during the period 2011- 2012) PLEASE RETURN THIS FORM DULY COMPLETED IN ALL RESPECT TO ACCOUNT DEPTT ON 30TH MAY 2011 COPIES OF RELEVANT RECEIPT/DOCUMENTS IN SUPPORT OF THE DECLARED INVESTMENT MUST REACH THE ACCOUNT DEPTT BEFORE 10 Feb 2012
Company Name Employee Name DOJ PAN Number MOBILE NUMBER Item Deduction Under Section 10 House Rent I am staying in a rented house and I agree to submit rent receipts when required.The Rent Paid is (Rs. 5000 X 12 months) & the house is located in a METRO. Sec 80D - Medical Insurance Premium (If the policy covers a senior citizen then exemption is Rs.20,000/-) Deduction Under Chapter VI A Sec 80DD - Medical treatment/insurance of handicapped dependant Sec 80E - Repayment of Loan for higher education ( only Interest ) Sec 80U - Handicapped Contribution to Pension Fund (Jeevan Suraksha) Life Insurance Premium Fixed Deposit with Scheduled bank with term not less 5 than yrs Public Provident Fund Deposit in Post Office Savings Scheme Deduction under Section 80C ULIP of UTI/LIC Principal Loan (Housing Loan) Repayment Mutual Funds Investment in Infrastructure Bonds Children Education Fee - restricted to a max of 2 children Deposit in NSC Others (please specify) Deduction under 80E Declared Amount If yes, Form 16 from previous employer or Form 12 B with tax computation statement Previous Employment Salary (Salary earned from 01/04/11 till date of joining) SALARY paid by the Previous Employer after Sec 10 Exemption PROFESSIONAL TAX deducted by the Previous Employer PROVIDENT FUND deducted by the Previous Employer INCOME TAX deducted by the Previous Employer Particulars AXEPP3106H 9953135260 Max Limit Declared Amount Ebix Software Asia Sez Pvt Ltd. Avanish Pal 9-Jan Employee ID D000557

84,000.00 Max Limit 15,000.00 50,000.00 50,000.00 Max Limit 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00 1,00,000.00

60,000.00 Declared Amount

Declared Amount

Income other than salary income

3 If yes, then Form 12C detailing other income is attached Max Limit Declared Amount

Deduction under Section 24

Date of Construction:

Interest on Housing Loan Interest if the loan is taken before 01/04/99

Date of Purchase:

150,000.00 30,000.00

Declaration: 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.

Date : Place:

23/12/2011 Noida Signature of the Employee Avanish pal

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