TAX DECLARATION FORM FOR INCOME TAX RELIEF - Y.E. 31.03.

2017
NAME OF COMPANY:
EMPLOYEE CODE NO.

LOCATION:
PAN:

(As appears on the Pay Slip)

(No Relief will be Given If PAN NOT mentioned)

NAME OF EMPLOYEE:

Rs. (No paise)

RENT PAID BY EMPLOYEE ( FOR HRA COMPUTATION PURPOSE ) For

employees who have joined during the year, the rent amount should only be from date of
joining the company till the year end. For Others it should be for the full year.

SEC.80D - MEDICLAIM PREMIUM (Max. Rs.55,000 = 25,000 + 30,000)

Sec.80DD Handicapped or Sec.80U Disability (Max. Rs.1,25,000)

SEC. 80CCC - JEEVAN SURAKSHA / OTHER PENSION SCHEMES

80E - EDUCATION LOAN INTEREST (Only Interest Component)

LOSS UNDER THE HEAD "INCOME FROM HOUSE PROPERTY"

INTEREST PAID IN RESPECT OF SELF-OCCUPIED PROPERTY Interest

on Loans taken after 01.04.1999 (Max. Rs.2,00,000)

SEC.80 EE - INTEREST PAID IN RESPECT OF NEW 1st TIME SELFOCCUPIED PROPERTY - (For Loan Sanctioned between 01.04.2016 to
31.03.2017 ONLY & Loan Less than 35 Lakh.) Property Value < 50 Lakh. Total
Interest Paid during FY 2016-17 cannot exceed Rs.50,000..

UNITS OF MUTUAL FUND [ Section 10(23D) ]

10 FIXED DEPOSIT WITH SCHEDULE BANK MORE THAN 5 YEARS.

11 LIFE INSURANCE PREMIA (by LIC or any other Insurer) - LIP
12 ULIP / DHANRAKSHA
13 PUBLIC PROVIDENT FUND - PPF (Max. Rs.1,50,000)
14 HOUSING LOAN REPAYMENT - PRINCIPAL AMOUNT
15 NATIONAL SAVINGS CERTIFICATE SERIES - NSC
16 ACCRUED INTEREST ON NSC
17 TUITION FEES PAID TO UNIVERSITY, COLLEGE, SCHOOL

(As per
Rules)

18 SUKANYA SAMRIDDHI SCHEME (Max. Rs.1,50,000)

19 NATIONAL PENSION SCHEME - U/S 80CCD(1) - (Max. Rs.1,50,000)
20 NATIONAL PENSION SCHEME - U/S 80CCD(1B) - (Max Rs.50,000)
21 INFRASTRUCTURE BONDS (As per old Scheme)
I hereby declare that the information given above is correct and true in all respects and I request the company to allow me
the appropriate Income-tax exemption / relief.
I undertake to produce to the company, LATEST BY JANUARY 1, 2017, OR prior to leaving the company, appropriate
documentary evidence in respect of payments mentioned above. Failing this, I agree that the company wil be free to cancel
the exemption allowed and to recover from me the additional Income-tax arising there from.

Signature of Employee:
(Form without Signature is INVALID)

NAME OF EMPLOYEE: (in block letters)

Date: