TAX SAVINGS DECLARATION FORM FOR FINANCIAL YEAR 2010-2011 (Assessment Year 2011-2012)

NAME: Priyanka Khemka SEX: Female

EMP.CODE: PAN NO: BFHPK9939K
ADDRESS: S-141, Greater Kailash, Part 2, New Delhi (Ground Floor)

I hereby confirm that I will be investing/ contributing the following amounts for the purpose of rebate/deduction to be considered
in calculating my income tax for the financial year 2010-2011. I further undertake that wherever eligible investments are made in
the name of spouse/children/dependent parents, the same have been/will be made out of my current years income and claim
thereof has/shall not be made by anybody else. I further undertake to submit all the Investment Proofs and Rent Receipts (if any)
on or before 5th March 2011 failing which the tax may be deducted accordingly from my salary.

I A Deduction to be claimed U/S 80 Amount (Rs.)

1 Mediclaim Policy Premium [u/s 80D]-upto Rs.15,000/-

2 Medical treatment of handicapped dependent [u/s80DB]-upto Rs.50,000/-
3 Medical treatment of specified diseases for self/dependent [u/s80DDB]-upto Rs.40,000/-
4 Deduction in case of self being totally blind or physically handicapped [u/s80 U]- upto Rs 50,000/-
5 INTEREST paid on loan taken for higher education [U/s 80 E]-upto Rs 40,000/-
Total Amount

B Interest on Housing Loan [u/s 24(2)] -- Maximum up to Rs.1,50,000

WILL BE APPLYING FOR A LON OF 15 LACS FOR 20 YEARS
C Rebate U/S 80C
1 Payment of Life Insurance Premium
2 Deposit in Public Provident Fund
3 Purchase of National Saving Certificates (NSC)
4 Payment of ULIP / Equity linked Mutual Fund 52000
5 Payment of tuition fees for any of two children
6 Repayment of Housing Loan (only Principal Amount)

(Incl. Registration fees for the first year of housing loan)

7 Interest on N.S.C. Purchased in The Previous 5 years
year of Purchase 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010
Amount Invested
(Rs.)
8 Pension Scheme
9 Other (Please provide details)
10 Infrastructure Bonds
Total Amount from 1 to 9 (Restricted to Rs. 1,00,000/-) & 10 (Restricted to Rs. 20,000/-)

II House Rent Allowance (H.R.A.)

Name & Add of Rent Amount (Per
Address of accommodation Rent Amount (Per Annum)
1 the Landlord Month)

2 The house is located in a Metro / Non Metro ( Please tick)

III Previous Employment Salary (Salary earned from 01-04-2010 till date of joining)
1 If Yes, Form 16 from previous employer or Form 12 B attached
2 If no form 16 or 12B attached, confirm whether the standard deduction and Working
3 Woman Rebate considered by the previous employer or not

I further undertake to submit all the Investment Proofs and Rent Receipts (if any) on or before 5th March, 2011.

I further undertake that wherever eligible investments are made in the name of spouse/children/dependent parents,
the same have been made out of my current years income and claim thereof has/shall not be made by anybody else.

I hereby declare that all the information given by me is true and correct and that I have not used this declaration to
get Income Tax rebate benefit anywhere else.

Place :
Date: Signature