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FORM A

1 NAME OF EMPLOYEE: (In Block Letters) EMPLOYEE PAYROLL CODE NO: (As it appears on the Payslip)

Forms Without Code Numbers Will NOT be accepted.


3 4 5 DATE OF JOINING: DEPARTMENT: INCOME-TAX PERMANENT A/C NO. : (Forms without PAN will NOT be accepted)

As undertaken by me in the Declaration for Income-tax Relief Form signed earlier, I now attach photocopies copies of receipts in respect of all payments made by me, details as under: 1. RENT

(a) I certify having paid (and shall pay) rent for the period April 1, 2014 (or from date of joining the present company whichever is later) to March 31, 2015 (or to the Date of Leaving the current company which ever is earlier) totalling Rs. _____________ (b) No. of rent receipts attached _________________________ (c) PAN OF LANDLORD _____________________________ ( PAN of Landlord is Compulsory if Rent is More than Rs.1,00,000 per annum or part thereof )

2.

SECTION 80D - MEDICAL INSURANCE PREMIA (a) I certify having paid during the year medical insurance premia for Myself / Spouse / Dependant Children totalling Rs. _____________ _________ Annexure marked No.

(Maximum. Rs.15,000 or Rs.20,000 if any one of the above is a Senior Ctiizen.) If you or your spouse is a senior Citizens (60 Years or above) please tick mark box >> (b) I certify having paid during the year medical insurance premia for My Parents totalling Rs. ______________ Annexure marked No. ____________ (Maximum. Rs.15,000 or Rs.20,000 if any parent above is a Senior Ctiizen.) If any parents is a senior Citizens (60 Years or above) please tick mark box >>> The Total of 3(a) and 3(b) above totalling to Rs. ______________.
3.

SECTION 80U Disability or Section 80DD Handicapped

I certify having incurred and paid expenses pertaining to a disability as per these sections and as per the Rules qualified therein. Rs._______________ Annex No. _______ Please provide certificate mentioning the Percentage of Disability here as Annex No. ______. Also Attach a valid copy of the Certificate issued by the required Medical Authority as Annex. No,__________. No Relief will be given if failure to attach either certificate. Page1

4.

SECTION 80 CCC JEEVAN SURAKSHA / OTHER PENSION SCHEMES (Maximum of Rs.1,00,000) I certify having paid from my income of the year chargeable to tax, premium of Rs._________ I am attaching herewith copies of receipt marked as Annexure No.____________.

5.

SECTION 80 E INTEREST PAYABLE IN RESPECT OF EDUCATION LOAN

I certify having taken an education Loan as per the Provision of this section. The amount mentioned here pertains ONLY TO THE INTEREST PORTION OF THE LOAN Rs.____________________. As Per Annexure No. _________________________. being

6.

LOSS UNDER THE HEAD INCOME FROM HOUSE PROPERTY (To be filled in when employee lets out any house property during the year)

I have incurred an aggregate loss under the head Income from house property Rs.________ I attach herewith a computation of the same as an Annexure No. _________to this declaration along with copies of all relevant receipts e.g. rent receipts issued to the tenant, municipal taxes, ground rent receipts, copy of lease agreement, etc. The onus of correct computation in this point is solely the responsibility of the Employee and the Employer will not be held accountable for the same.

7.

INTEREST PAID IN RESPECT OF SELF-OCCUPIED HOUSE PROPERTY (to be filled in only when employee has not let out any house property during any duration during the year - maximum amount eligible for deduction is Rs.1,50,000)

I certify having paid Rs._______________ for the year ending 31st March, 2015, as interest on loan taken for acquiring OR constructing my self-occupied property situated at:
___________________________________________________________________________

___________________________________________________________________________

I furnish herewith a receipt from the lender Annexure No. __________ of the interest paid for the year, along with the Permanent Account Number and the address of the Lender. I confirm that the aforesaid house property or any portion thereof has not been let out during any period of the year and no other benefit has been derived from it by me. (Maximum of Rs.1,50,000)

8.

INTEREST PAID IN RESPECT OF NEW SELF-OCCUPIED HOUSE PROPERTY

Loan taken after 01.04.2013 and before 31.03.2014 AND Loan LESS THAN Rs. 25 Lakh
I certify having paid Rs._______________ for the year ending 31st March, 2015, as interest on NEW LOAN taken for acquiring OR constructing my self-occupied property situated at:
___________________________________________________________________________________

I furnish herewith a receipt from the lender Annexure No. __________ of the interest paid for the year, along with the Permanent Account Number and the address of the Lender. Page 2

9.

UNITS OF MUTUAL FUND AS PER SEC 10 (23D) APPROVED BY THE CBDT

I certify having paid from my income of the year chargeable to tax, towards the following: (Maximum of Rs.1,00,000) Allotment Letter No./ Date of Allotment Amount Name of Mutual Fund Share Certificate No.

Total Rs.

I am attaching herewith copies of allotment letter/share certificate marked as Annexure No.___________

FIXED DEPOSIT WITH SCHEDULE BANK MORE THAN 5 YEARS: (Maximum of Rs.1,00,000) Name of Bank Fixed Deposit No. Date of Allotment & Date of Matuity

10.

Amount

Total Rs. (Maximum of Rs.1,00,000) I am attaching herewith copies of the Fixed Deposits marked as Annexure No.___________

11.

LIFE INSURANCE PREMIA / JEEVAN DHARA / JEEVAN AKSHAY ANY OTHER LIFE INSURANCE POLICY:

I certify having paid, from my income of the year chargeable to tax, insurance premia, details as under: (Maximum of Rs.1,00,000) Policy No. Date of Payment Premia Amount Vr. No.

Total Rs. PLEASE DO NOT ATTACH COPIES OF POLICIES. ONLY PHOTOCOPIES OF RECEIPTS OF PREMIA PAID SHOULD BE ATTACHED. ALL PREMIA RECEIPTS SHOULD REFLECT DATES BETWEEN APRIL 1st, 2014 TO MARCH 31st, 2015. Page 3

12.

ULIP/DHANRAKSHA

I certify having paid, from my income of the year chargeable to tax, premiums towards my ULIP/DHANRAKSHA policies, details as under: (Maximum of Rs.1,00,000) Policy No. Date of Payment Premia Amount Vr. No.

Total Rs.

13.

PUBLIC PROVIDENT FUND (PPF) - Max. Rs.1,00,000

I certify having paid, from my income of the year chargeable to tax, deposits into my PPF Account No. ________________, details as under: Vr. No. Date of Payment Deposit Amount

Total Rs.

14.

HOUSING LOAN REPAYMENT - Max. Rs.1,00,000

I certify having repaid during the year housing loan taken by me from __________________________________________ totalling Rs. _______________I further certify that this amount represents the payment towards the principal amount only and does not include payment of any interest. The relevant certificate is attached herewith and marked Annexure. No. __________. (Maximum of Rs.1,00,000)

15.

NATIONAL SAVINGS CERTIFICATES SERIES

I certify having purchased, from my income of the year chargeable to tax, the under mentioned NSC Issue: (Maximum of Rs.1,00,000) Vr. No. Date of Payment Deposit Amount

Total Rs.

Page 4

16.

ACCRUED INTEREST ON NSC SERIES

I certify that the interest accrued in respect of my NSC for the year ending March 31, 2015 is Rs. ___________________. I give below the year wise detailed working of the interest accrued in support of the above stated amount:- (Maximum of Rs.1,00,000) Date of Purchase NSC Deposit Amount Accrued Interest NSC Cert. Number

Total Rs.

17. TUTION FEES PAID (Max. 2 Children, Please refer Income Tax Rule) (Maximum of Rs.1,00,000) Vr. No. Particulars Date of Payment Amount Paid

Total Rs.

18. Vr. No.

INFRASTRUCTURE BONDS: (Up to a maximum of Rs.1,00,000) Date of Payment Deposit Amount

Total Rs.

I hereby declare that the information given above is correct and true in all respects. I request the Company to allow me the appropriate Income-tax rebate/relief. If any of the above details is incorrect, the Company will not be responsible or liable to any tax liability on behalf of the employee. Signature Of Employee: __________________________________

Name (in block letters):

__________________________________

Signature of Regional/Location Manager, H.R. / Finance/ Local Finance functionary: confirming that the detail and documentary --------------------------------------------------evidence contained in this form have been checked and verified with originals and are found to be in order.

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