INCOME TAX DECLARATION FORM FOR 2012-13

( To be used to declare investment for Income Tax that will be made during the period 2012-2013)
Company Name Employee Name DOJ PAN Number Item Particulars Deduction Under Section 10 I am staying in a rented house and I agree to submit rent receipts when required.The Rent Paid is (Rs. _________ X ______ months) & the house is House Rent located in a METRO / NON METRO ( Tick whichever is applicable). Please Fill Allowance Annexure - I I will produce the Medical bills to the Satisfaction of the company for my eligibility of Rs, 15000/- as per Income Tax Act or else the company can consider the amount paid as taxable I will produce all bills to the Satisfaction of the company for the telephone claims or else the company can consider the amount paid as taxable I will produce all bills to the Satisfaction of the company for the conveyance claims or else the company can consider the amount paid as taxable I will produce all bills to the Satisfaction of the company for the books and periodicals reimbursements or else the company can consider the amount paid as taxable Max Limit Sec 80D - Medical Insurance Premium (If the policy covers a senior citizen then exemption is Rs.15,000/-) Sec 80DD-Medical treatment/insurance of handicapped dependant,disability >80% Rs 75000/Sec 80DDB - Medical treatment (specified diseases only)Senior Citizens upto Rs 60000/Sec 80E - Repayment of Loan for higher education for SELF ( only Interest ) Sec 80U - Permanent Physical Disability. Severe disability Rs75000/100,000.00 Max Limit 10,000.00 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 24,000.00 1,00,000.00 1,00,000.00 1,00,000.00 Declared Amount Refer Note 1 Refer Note 1 Refer Note 1 Refer Note 1 Refer Note 1 Refer Note 1 Refer Note 2 Refer Note 1 Refer Note 1 Refer Note 1 Refer Note 1 Refer Note 1 0 Declared Amount Previous Employment Salary (Salary earned from 01/04/06 till date of joining) If yes, Form 16 from previous employer or Form 12 B with tax computation statement 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 15,000.00 50,000.00 40,000.00 Refer Note 2 Refer Note 1,3 Refer Note 1,3 Refer Note 1 Declared Amount Refer Note 1 Employee ID Residential Status

Max Limit

Declared Amount Rent receipts for the year / Lease/Rent Agreement

Medical Bill Reimbursement Reimbursements Telephone Reimbursements Conveyance Reimbursements Books & Periodicals Reimbursements

15,000.00

Medical Bills

Per Month Landline/ Mobile/ Internet Bills Petrol/Diesel Bills & Repair bills Bills

Deduction Under Chapter VI A

Deduction under Section 80C

Sec 80CCC - Contribution to Pension Fund (Jeevan Suraksha) Life Insurance Premium Deferred Annuity Public Provident Fund Deposit in Post Office Savings Scheme / Fixed Deposits in Banks > 5 yrs ELSS / Unit Linked Insurance Plan of UTI / LIC Repayment of Principal Housing Loan Mutual Funds Children-Tuition Fee - Rs.12000/- per child restricted to a max of 2 children Deposit in NHB Deposit in new purchases of NSC Others (please specify)

Income other than salary income

If yes, please fill Annexure - II. Declared Amount Refer Note 2 Refer Note 2

Max Limit Interest on Housing Loan 150,000.00 Deduction under Section 24 Note : Form 12 C along with the calculation of loss on house property needs to be attached for considering the above

Declaration: 1) I, do hereby declare that the information given above is correct and true in all respects. 2) Further, I will ensure to submit the actual proof of investment on / before 31 Dec 2012 failing which i authorise the company to deduct Income Tax without considering investments for which documents are not provided from my salary wef Jan 2013. Date : Place : Bangalore

Signature of the Employee

Notes

1) Kindly attach receipt copy of payment made during the Financial Year 2012-13. In case current year's receipt is not available please send us the copy of receipts whenever paid during the year, but certainly before 31st Dec 2012. 2) For Interest / Principal repayment of Housing Loan / Education Loan, please attach a copy of Certificate for the Financial Year 2012-13 issued by the Financial Institution/Bank in the name of the employee.
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