Employee Investment Declaration Form For the Financial Year 2016-2017

Employee ID *
Employee Name *
PAN No (Attach Photocopy)*
Date of Joining
Gender *
Address for claiming HRA:
From Date To Date City Metro Yes/No PAN of Landlord Rent Paid per
month

Section B - Chapter VI A - Deductions from Total Income AMOUNT

Medical Insurance Premium (U/s 80D) - Individual, Spouse & Children (Max Limit INR 25,000 p.a)
Medical Insurance Premium (U/s 80D) - Parents not being Senior Citizens (Max Limit INR 25,000 p.a)
Medical Insurance Premium (U/s 80D) - Parents being Senior Citizens (Max Limit INR 30,000 p.a)
Medical Treatment/Handicapped Dependent (U/s 80DD) <80%
Medical Treatment/Handicapped Dependent (U/s 80DD) >80%
Medical Treatment in case any Disease/ Ailment-Self/Dependent (U/s 80DDB) Senior citizens (> 60 years and < 80
years)
Medical Treatment in case any Disease/ Ailment-Self/Dependent (U/s 80DDB) Super Senior citizens (> 80 years )
Interest on Educational Loan (U/s 80E)
Permanent Physical Disability (80U) < 80%
Permanent Physical Disability Severe Disability (80U) > 80%
Rajeev Gandhi Equity Savings Scheme (80CCG)
Interest on Deposit in Savings Account deduction upto Rs.10000 (80TTA)
National Pension Scheme(80CCD)
Total 0
Section C - Chapter VIA Sec 80C
Life Insurance Premium
Public Provident Fund (PPF)
National Savings Certificate (NSC)
Infrastructure Bonds
Children Education Tuition Fees
Mutual Funds / Equity Linked Saving Scheme (ELSS)
Sukanya Samriddhi Scheme
ULIP
5 Year Time Deposit in Post Office
Housing Loan - Principal Amount paid, Registration Fees, Stamp duty
Fixed Deposit Scheme (Block Period of 5 yrs)
NSC Interest (Will be considered as Other Income)
Total (Maximum Limit INR 150,000) 0
Section D - Loss from House Property - SELF OCCUPIED
Total interest paid by me (post construction/possession/ amortized pre-emi) during the financial year (April 16 to
March
Address 17)
of -the
SelfProperty
Occupiedagainst which Loan taken
City
Date of Occupation (DD/MM/YYYY)
Total (Maximum Limit INR 250,000 - Refer Annexure 1 attached to the document) 0
Section E - Previous Employment - Refer Annexure 2a and 2b attached to the document
Income after Section 10 exemption (Joined after 01/04/2016)
Provident Fund (PF)
Professional Tax (PT)
Tax deducted at source (TDS)
(Please attach Form 16 OR Income Tax Computation Sheet from Previous Employer for FY 2016-17along with 0
12B)Total
Grand Total 0

Declaration:
I hereby declare that the information given above is correct and true in all respects and I intend to make the investments declared above
I also undertake to indemnify the company for any loss/liability that may arise in the event of the above information being incorrect /
declared investments not made
Date:
Place:
Signature of the employee
Annexure-1
Interest on Housing Loan for the FY 2016-17.

Note:

1.Interest on Housing loan allowed up to Rs.2,00,000.

2. Additional exemption of INR 50,000 provided the following conditions are satisfied:
a. First Home Buyer/Buyers; and
b. Value of the House is less INR 50 lacs; and
c. Maximum value of the loan is INR 35 lacs.

2. Sanction Letter/Provision Certificate is mandatory for claiming interest on housing loan.

 FORM NO. 12 B
[See rule 26A]
ANNEXURE 2a
Form for furnishing details of income under section 192(2) for the year ending 31st March, ____________________

Name of the employee Permanent Account No.

Residential Status
Address of the employee

Particulars of salary as defined in Section 17, paid or

due to be paid to the employee during the year

Amt Total
deducte amount
TAN of Permane Total amount of d in of tax
the nt house rent respect deducte
allowance, Value of
Name & Address of employe Account Period of Total amount perquisites and Total of of life d during
Sr No. r(s) as Number Employ of salary conveyance amount of Columns insuranc the year Remarks
employer (s) allotted of the ment allowance and 6, 7 & 8 e (enclose
excluding accretion to
by the Employe amounts other allowances employee's premiu certificat
ITO r (s) to the extent m, PF etc e issued
required to be chargeable to tax provident fund
shown in account (give (give under
columns 7 & 8 [see section details in the details) sec 203)
10(13A) read with annexure)
rule 2A and
section 10(14)]

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Verification

I _________________________________, do hereby declare that what is stated above is true to the best of my knowledge and belief, verified today _______________

Signature of the Employee ___________________________

 ANNEXURE
[ See column 8 of Form No.12B ]
ANNEXURE 2b
Particulars of Value of perquisites and amount of accretion to employee's fund account

Name of the employee Permanent Account No.

Period : Year ending

Address of the employee

Value of rent-free accommodation or value of any concession in rent for the accommodation
provided by the employer (give basis of computation) [See rules 3(a) and 3 (b)

Estimated
Where accommodation is furnished Whether any Value of value of any
conveyance free or other benefit
has been Remunera concessio or amenity
provided by tion paid nal provided by Interest
the employer by passages the employer, credited to
free or at a employer on home free of cost or Employer's the
concessional for leave and at contributio assessee' s
Value of n to account in Total of
perquisite rate or where domestic other concessional
Cost of furniture the employee and/or traveling rate not recognised recognised columns 9
TAN/PAN of Where (including (column 3 PF In excess provident to 15
Rent, if minus is allowed the personal to the included in
Name of the employee the accomm television sets, Perquisite use of one or services extent the preceding of 10% of fund in carried to
employer odation radio sets, Value of any, paid column 8 the excess of column 8
by the or column more motor provided chargeabl columns (give
is refrigerators, furniture cars owned or to the e to tax details), e.g. employee's the rate of Form
Value as if other household (10% of Total of employe 7 minus salary [See fixed by the No.12B
unfurnis e column 8 hired by the employee (give 'supply of gas,
hed accommodation appliances and column 5) Columns 4 employer, (give details) electricity or Schedule Central Govt
is unfurnished air-conditioning OR actual and 6 as may be IV-Part A] [See
applicable estimated details) [See rule water for
plant or hire value of [See rule 2B read household Schedule IV-
equipment) OR charges ) Part A]
perquisite 3(g)] with consumption,
hire charges, if payable (give details) section free
hired from a [See rule 3 10(5)(ii)] educational
third party faci

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Signature of the Employee________________________
Important Information:
For Individuals the Tax Rates as below for the FY 2016-17

Income Rs. Rate of Income Tax

Upto Rs. 2,50,000 NIL

Rs. 2,50,001 to Rs. 5,00,000 10% of Income above Rs. 2,50,000
Rs. 5,00,001 to Rs. 10,00,000 Rs. 25,000 + 20 % of Income Above Rs. 5,00,000
Rs. 10,00,001 and above Rs. 125,000 + 30 % of Income Above Rs. 10,00,000

Note:
1.Education Cess @3% as applicable
2.Tax Rebate of Rs.5,000 for total annual income up to Rs. 5lakh (As per Section 87A)

NOTE:
1.Rent Receipt
2.PAN of the Owner with address is mandatory in case the rent exceeds Rs.8,300/-Per Month
3.Copy of Rental agreent is mandatory if rent payable is more than Rs.8,300/-Per Month