INCOME TAX DECLRATION FORM FOR THE YEAR 2015-16 (A. Y.

2016-17)
(To be used to declare investment for Income Tax that will be made during the period 2015-16)
Company Name
Employee Name
Employee No.
Date Of Joining
PAN Number
Married or Not
No. of Child
Whether any staff car/vehicle provided(Y/N)
I hereby declare and intend to claim rebate in the current Financial Year (2015-16), under Income Tax Sections as indicated below.
herewith requisite self attested Xerox copy of documents to claim rebate.
Sr. No.
1

Nature of Savings / Rebate

HRA Rebate under I.Tax Rule-2 A and u/s 10 (13 A)
Monthly Rent Paid Rs.____p.m. Rent receipt duly verified by Estt.
Concerned are enclosed herewith.
PAN NO. OF LANDLORD________
Interest on Loan borrowed for construction /acquisition of a house property
u/s Sec 24.
Details of House Building Loan

Section of IT Act Maximum Limit

10 (13 A)

24

As per Rule

200,000

Details of
Transaction

Amount of Loan Date/Year- In Which Loan Disbursed.

Date of Completion Certificate of House Or Date Of Possession/Occupation
Of House
Income/Loss From House Property (Enclose Computation-Form 12C )
(The maximum amount of deduction allowable is Rs.200000/- in case of self occupied property acquired or constructed w
borrowed on or after 01-04-1999 and acquisition or construction of the housing property is made within 3 years from the
financial year in which the capital was borrowed)
3

Medical Expenses Reimbursement on basis of availability of supporting

otherwise this will be taxable. For very senior citizen above the age of 80
years, not eligible to take health insurance, deduction is allowed for Rs
30,000 toward medical expenditure.

LTA Exemption- I have taken exemption for LTA in the following years

5
5(a)

15,000.00

As per LTA Rule

During the year 2014

Yes/No
During the year 2015
Yes/No
During the year 2016
Yes/No
During the year 2017
Yes/No
If I do not produce the bills to the satisfaction of the Company, then the Company can consider the amount paid towards
taxable
Rebate
under u/s 80C, 80CCC & 80 CCD(1)
150,000
Life Insurance Premium
80 C
Deferred Annuity
Public Provident Fund
Deposit in Post Office Savings Scheme
ULIP of UTI/LIC
Principal Loan (Housing Loan) Repayment
Mutual Funds
Investment in Infrastructure Bonds
Tuition fee excluding development fee & donation (Upto 2 children)
Deposit in NHB

5(b)
5(c)
6
7

Deposit in NSC
Fixed Deposits with Scheduled Bank for period not less than 5 years
Any deposit made in Sukanya Samridhi A/c
Others (Please Specify) PF + PT
Pension Scheme Investments/Jeevan Suraksha upto Rs. 1.00 Lac.
Contribution to New Pension Fund (Employee and Govts share both)

80 CCC
80 CCD (1)

Additional deduction in respect of any amount paid to New Pension

Scheme
Rajiv Gandhi Equity Savings Scheme (RGES) {Max. of 50% of the amount
invested to the extent that the said deduction does not exceed Rs. 25,000/and shall be allowed only to first time investors}

80 CCD (1B)

50,000

80 CCG

25,000

Mediclaim Policy Other Individuals

Senior Citizen (60 years and above)
Very Senior Citizen (80 years and above) - who are normally not covered
by such medical insurance schemes, it is also proposed to provide that
any payment made on account of medical expenditure in respect of a
very senior citizen, if no payment has been made to keep in force an
insurance on the health of such person, as does not exceed thirty
thousand rupees shall be allowed as deduction under section 80D.

80 D

Expenditure for medical treatment or deposit made for handicapped

dependent with dependent with disability . Certificate from Prescribed
Authority in Form No. 10-IA is required

80DD

25,000
30,000
30,000

1. With more than or equal to 40% disability Rs. 75,000/- (Fixed Amount)

75,000

2. With severe disability more than or equal to 80% - Rs. 1,25,000/10

11
12

13

14

Note
A
B
C

Medical treatment of Assesse or a dependent for specified diseases (Cancer,

AIDS, Neurological, Chronic, Renal Failure) - Certificate from Prescribed
Authority in Form No. 10-I
Other Individuals
Senior Citizen (60 years and above)
Very Senior Citizen (80 years and above)
Interest on Loan for Higher Education-of employee or the higher education
of his/her spouse /children (Without any limit)
Employee suffering from disability
1. With more than or equal to 40% disability- Rs.75000/- (Fixed Amount )
2. With severe disability more than or equal to 80% deduction of
Rs.1,00,000/- shall be allowable
Previous Employment Salary (Salary earned from 01/04/15 till date of
joining)
If yes, Form 16 from previous employer or Form 12B 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
Income other than salary income
If yes, then Form 12C detailing other income is attached

125,000
80DDB

80 E

40,000
60,000
80,000
No Limit

80 U
75,000
100,000

PAN Number should be mentioned along with the IT Declaration Form otherwise the Form shall not be accepted
Please fill up only actual invested amount of current Financial year commencing from 01-04-2015 in amount Column.
The requisite documents for claiming the HBA rebate must be enclosed with the declaration form as per detail given under :

1
2
3
4

Possession/allotment letter and Sanction Letter of Loan in respect of property for which rebate of HBA claimed.
Accrued HBA Principal/Interest certificate from the Borrowing Authority/Bank for the F.Y-2015-16.
Bank Statement showing the Housing Loan Instalments /deductions.
Detailed calculation on account of rent/deemed rent of Vacant Flats/House's which is let or deemed to be let out should be p
furnished.

I, declare that the above statement is true to the best of my knowledge and belief. In the event of any change that may occ
the year pertaining to the information given in the form, I undertake to inform the same to the company. Income Tax liab
due to failure, if any, for not making / not intimating payment / investment made or proposed to be made by me and / or a
declaration would be my responsibility.

I further undertake to provide all documentary proofs of payment made by me before 15th March 2016 and if I fail to do
company can make full deduction of income tax dues from March 2016 salary.

Place
Date

Signature of Employee
Name_________________

as indicated below. I enclose

Declared Amount

red or constructed with capital

hin 3 years from the end of

mount paid towards LTA as

accepted
ount Column.
detail given under :-

laimed.

e let out should be positively

change that may occur during

any. Income Tax liability arising
ade by me and / or any wrong

16 and if I fail to do so, the

ure of Employee
__________________________

FORM NO. 12B

[See rule 26A]
Form for furnishing details of income under section 192(2) for the year ending
Name and address of the employeePermanent Account No.Residential statusParticulars of salary as defined in section 17, paid or due to be paid to the
employee during the year

S.No

Name and address of

employer(s)

TAN of the
employer(s) as
allotted by the
ITO

Permanent Account Number

of the employer(s)

Period of
employment

Total amount of
salary excluding
amounts required
to be shown in
columns 7 and 8
6

Total amount of house rent

allowance, conveyance
allowance and other allowances
to the extent chargeable to
tax[See section 10(13A) read
with rule 2A and section
10(14)]
7

With effect from 1-4-1991, section 80C has been replaced by section 88.
Verification
I, Mr. ---------------------- do hereby declare that what is stated above is true to the best of my knowledge and belief.
Verified today,
Place

ANNEXURE
[See column 8 of Form No. 12B]
Particulars of value of perquisites and amount of accretion to employee's provident fund account
Name and address of the employeePermanent Account No.Period : Year ending

Value of rent-free accommodation or value of any concession in rent for the accommodation provided by the employer (give basis of com
Where accommodation is furnished

Name of the
employee

TAN/PAN of the
employer

Where
Value as if accommodation is
accommodation
unfurnished
is unfurnished

Cost of furniture (including television sets, radio sets, refrigerators,

other household appliances and air-conditioning
plant or equipment) OR hire charges, if hired from a third party

ANNEXURE
(Contd.)

Remuneration paid
by employer for
Value of free or concessional
domestic and/or
passages on home leave and
Whether any conveyance has been provided by the employer free or at a concessional rate or
Name of the
personal services other travelling to the extent
where the employee is allowed the use of one or more motor cars owned or hired by the
employee
provided to the chargeable to tax (give details)
employer, estimated value of perquisite (give details) [See rule 3(c)]
employee (give [See rule 2B read with section
details) [See rule
10(5)(ii)]
3(g)]

Name of Employee:Place

10

11

12

Signature
Date:-

tion 17, paid or due to be paid to the

ring the year

Total amount
Amount deducted in
of tax
respect of life
deducted
insurance premium,
Total of columns
during the year
provident fund
Remarks
6, 7, and 8
(enclose
Value of perquisites
contribution, etc., to
certificate
and amount of
which sec. 80C
issued under
accretion to employee's
applies (Give details)
section 203)
provident fund account
(give details)
8
9
10
11
12

Signature of the employee

Signature of the employee

loyee's provident fund account

odation provided by the employer (give basis of computation)[See rules 3(a) and 3(b)]
dation is furnished
Value of
perquisite
(column 3
minus
Rent, if any,
Perquisite value of furniture (10% of Total of columns 4 and
column 8 or
paid by the
column 5) OR actual hire charges payable
6
column 7
employee
minus
column 8 as
may be
applicable)
6

Estimated value of any other benefit or

amenity provided by the employer, free of
cost or at concessional rate not included
in the preceding columns (give details),
e.g., supply of gas, electricity or water for
household consumption, free educational
faci

13

Interest
credited to the
assessee's
Employer's
account in
contribution to
recognised
recognised provident
provident fund
fund in excess of 12%
in excess of
of the employee's
the rate fixed
salary [See Schedule
by the Central
IV - Part A]
Government
[See Schedule
IV - Part A]

14

Signature of the employee

15

Total of
columns 9
to 15
carried to
column 8 of
Form No.
12B

16

FORM NO. 12C

Form for sending particulars of income under section 192(2B) for the year ending 31st March, ...

1 Name and address of the employee

2 Permanent Account Number
3 Residential status
4 Particulars of income under any head of income other than salaries (not being a
loss under any such head other than the loss under the head Income from house
property) received in the financial year
Rs.

Rs.

(i) Income from house property

(in case of loss, enclose computation thereof)
(ii) Profits and gains of business or profession
(iii) Capital gains
(iv) Income from other sources
(a) Dividends
(b) Interest
(c) Other incomes

0
0
0

5 Aggregate of sub-items (i) to (iv) of item 4

6 Tax deducted at source [enclose certificate(s) issued under section 203]

Place ....................
Date ....................

Signature of Employee
Name__________________
Verification

I, ........................................ do hereby declare that what is stated above is true to the best of my knowledge and belief Verified today,
the ........................................ day of ..................................

Place ....................
Date ....................

Signature of Employee
Name__________________