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Investment Declaration Form for FY 2012-13

NAME GENDER DOB EMP NO PAN D O JOINING Amount declared by you in the Declaration form AMOUNT RS. Please enter your Monthly Rent details as per the Rent Receipt / Lease Deed. Note:If the Employee is paying the rent below Rs.3000/- per month, he/she need not furnish the Rent Receipts (Circular No:8/2007 Dt: 05.Dec.2007).

S.NO. 1

PARTICULARS Rent Paid / Payable for: April 2012 May 2012 June 2012 July 2012 August 2012 September 2012 October 2012 November 2012 December 2012 January 2013 February 2013 March 2013 TOTAL PARTICULARS Interest on Housing Loan u/s 24 (If the house is self occupied and the loan was taken before April 1999). Bankers Certificate to be submitted Interest on Housing Loan u/s 24 (If the house is self occupied and the loan was taken on or after April 1999). Bankers Certificate to be submitted Interest on Housing Loan u/s 24 (Let out/ Deemed to be let out) Bankers Certificate to be submitted [if the property is LET OUT - Rental Income need to be specified]

Remarks

Please Fill in (Metro / Non Metro)

0
MAXIMUM LIMIT (RS.) Upto Rs. 30000/(If Self Occupied) AMOUNT RS. REMARKS
Provisional Certificate issued by the Banker showing the Interest Part

S.NO.

Max Limit - Rs. 1,50,000/(If Self Occupied)

Provisional Certificate issued by the Banker showing the Interest Part

Rental Income for the Period April 2012 March 2013

- No Limit (If Let Out)

Municipal Taxes PAID by the owner (employee) during the financial year

S.NO.

PARTICULARS 3 Medical Allowance

MAXIMUM LIMIT (RS.) Rs.15,000/- per annum

AMOUNT RS.

REMARKS
Medical expenses incurred for family: (Family includes spouse, children and dependent parents, brothers and sisters )

Medical Insurance Premium PAID by Employee: - on the health of employee, spouse, and dependent children. [Rs.20,000/- In case employee is a Senior Citizen] (i.e., 60 years or more). Rs. 15,000/- (or) Rs.20,000/Payment made by an employee for preventive health check-up of self, spouse, dependent children during the financial year is eligible for maximum deduction of Rs 5000. Note: The amount paid is within the overall Additional Amount of Rs.15,000/Medical Insurance Premium PAID by Employee on the health of parents (even
not dependent on employee) . [Rs.20,000/- In the case parents are Senior Citizen]i.e., 60 years or more

Sec 80D (Medi Claim Policy & Preventive health check up)

Rs. 15,000/- (or) Rs.20,000/-

Sec 80DD (Maintenance including Medical Rs. 50,000/- (Rs.1,00,000/- for treatment of dependant person with Severe disability) disability)

payment made by an employee for preventive health check-up of parents during the financial year is eligible for maximum deduction of Rs 5000. Note: The amount paid is within the overall limits ( Rs. 15000/Rs. 20000). Here Employee gets fixed amount of deduction. If employee has incurred any expenditure / deposited in specified policy. (Form 10-IA obtained from Medical Authority has to be submitted)

Sec 80DD (Maintenance including Medical Rs. 50,000/- (Rs.1,00,000/- for treatment of dependant person with Severe disability) disability)

Here Employee gets fixed amount of deduction. If employee has incurred any expenditure / deposited in specified policy. (Form 10-IA obtained from Medical Authority has to be submitted)

Rs. 40,000/Sec 80DDB (Medical treatment for specified (Rs. 60,000/- for Senior Citizen diseases or ailments) - Self / Dependents )

Here Employee gets deduction: Lower of the following: i). Amount incurred or ii). Rs.40,000/- (or Rs.60,000/- if expenses incurred for senior citizen i.e,60 years or more ) (Form 10-I obtained from Medical Authority has to be submitted) Interest on Loan taken for Higher Education: Amount paid by employee during the financial year on loan taken for higher education of - Employee, spouse or children of employee or students for whom employee is a legal guardian Benefit Period: Current Period + Next 7 years Here Employee gets fixed amount of deduction. (Form 10-IA obtained from Medical Authority has to be submitted)

Sec 80E (Education Loan)

No limit (only Interest Portion)

Sec 80U (For person with a disability)

Rs.50,000/- (Rs.1,00,000/- for Severe disability) Amount declared by you in the Declaration form AMOUNT Rs.

S.NO.

PARTICULARS

MAX BENEFIT PERMISSIBLE (RS.)

REMARKS

9 10 11 12 13 14 15 16 17 18 19 20 21 22 S.NO. 23

Life Insurance Premium Public Provident Fund (PPF) Voluntary Provident Fund (VPF) Pension Fund Contribution National Savings Certificate (NSC) Interest Accrued on NSC (Reinvested) Maximum amount eligible for Unit Linked Insurance Policy (ULIP) Equity Linked Savings Schemes (ELSS) Deduction under section 80C & Mutual Funds 80CCC Categories is Payment of Tuition fees for Children (Max 2 Rs.1,00,000/Children) Principal repayment of Housing Loan Registration charges incurred for Buying House (I year Only) Infrastructure Bonds Bank Fixed Deposit for 5 Years & above Post office Term Deposit for 5years & above TOTAL PARTICULARS a) Interest Income from Savings A.c (Banks & Post office only) b) c) d) PARTICULARS AMOUNT AMOUNT

Self , Spouse & Children only Self , Spouse & Children only will be additionally deducted from salary Self only Self only Self only Self , Spouse & Children only Self only Two children only Self & Joint a/c holder Self only Self only Self only Self only

S.NO. 24

Income From Previous Employer (Joined after 01/04/2012) a) Income after exemptions Form 16 or Tax computation from b) Provident Fund (PF) previous employer should be furnished c) Professional Tax (PT) d) Tax deducted at source (TDS) I here by declare that Information as stated above is true and correct . I also authorize the company to recover tax (TDS) from my salary based on the PROOFS Submitted by me. I am personally liable to Income Tax proceedings for any misstatements in the declaration or proofs submitted herewith if they are inconsistent with the requirement of Income Tax Act, 1961.

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Date: Place: Signature of the Employee

a) Date of actual possession of property [which can be validated by 'Possession Certificate' issued by builder/municipal authorities etc.] b) Amortisation of pre-construction period interest (if any) incurred [which needs to be considered during Current FY 2012 - 13] (Amount)

c) Information towards the House Property (LET OUT ) - In case of more than 1 Let out House Property % of Rental Income Per Muncipal Taxes Principal portion paid in the House Property Owner Annum Per Annum Financial Year Ship i) House Property 1 ii) House Property 2 iii) House Property 3 iv) House Property 4

Guidelines to FILL
1. Metro City Mumbai / Delhi / Calcutta / Chennai 2. Non Metro City All Other Cities 3. Please fill in and submit the same along with the Supporting documents 4. All the HRA Bills / Medical Bills / LTA Bills / Provisional Loan Certificate for House from Banker - should be ORIGINAL 5. Provisional Loan Certificate for House from Banker - should be submitted in respect All the properties declared by employee in the above table 6. As per the provisions of the Income Tax Act 1961 - HRA Exemption will not be provided, if the Employee is staying at his SELF OCCUPIED House Property [if the Employee has claimed BOTH HRA & Interest on Self Occupied HP - For Tax Declaration ONLY one among them will be considered] 7. In case of Self Occupied / Let Out House Property the Employee has to mention the "Interest on Housing Loan" / "Principal repaid Amount" Please mention - Full amount of "Interest" / "Principal" along with the % of Owner ship