DECLARATION FOR HOUSE RENT ALLOWANCE RELIEF FINANCIAL YEAR 2012-13 Details of e!t a"t#all$ %ai&' a.

. Address of residential property in respect of which rent paid. __________________________________________________ __________________________________________________ b. c. d. Name of Landlord to whom rent is paid: ____________________________ Phone number of Landlord : ____________________________

Rent payable / paid during the Financial ear: Rs.____________________

()lease atta"* "o%$ of Lease + Re!t A, ee-e!t. I! "ase !o a, ee-e!t is e/e"#te& s#0-it "o%$ of ORI1INAL e!t e"ei%ts 2it* % o%e e3e!#e sta-%. I! "ase e!t e"ei%t is !ot s#0-itte&4 t*e elief 2ill !ot 0e ,i3e!.5 DECLARATION' i. ! hereby declare that ! shall inform immediately to the company any change in monthly rent stated abo"e or discontinuation of house rent payments. ii. ! also declare that no residential accommodations owned by me or by my spouse or by my child or by #$F of which ! am a member at the place where ! reside or perform the duties of employment. iii. ! hereby declare that what is stated abo"e is true and correct. Any !ncome %a& dues arising out of wrong declaration will be my sole responsibility.

Si,!at# e of t*e E-%lo$ee Date ' E-%lo$ee Na-e ' E-%lo$ee Co&e '