NAME OF THE COMPANY

DECLARATION OF INVESTMENTS MADE / TO BE MADE DURING THE YEAR APRIL 2010 TO MARCH 2011

Name of the Employee : PAN No :

Emp.No. / Department :

Residential Address :

Contact Number :

A. Deduction in respect of Contribution to Certain Pension Funds : (Section 80 CCC)

Policy No. Premium Paid on Premium Amount [Rs.]

B Deduction under section 80D, 80DD, 80DDB, 80U [Please specify]

Mediclaim Policy / Medical Expenditure / Disability

Section 80D - ( Medical Insurance Premium paid on the health of the tax payer, spouse, dependent
parents or dependent children)

Section 80DD - ( Medical treatment of a handicapped per dependent who is a person with disability)

Section 80DDB - ( Expenditure incurred for the medical treatment of assessee / Spouse / Children /
Parents)

Policy No. Premium Paid on Premium Amount [Rs.]

C Amount contributed for rebate under section 80C of the Income Tax Act:
1. Life Insurance Premium:
Policy No. Sum Assured [Rs.] Premium Amount [Rs.]

2. Public Provident Fund:

Name of Bank & Branch Account No. Amount [Rs.]

3. National Savings Certificate:

Contact No. Date of Issue Amount [Rs.]
 4. Unit Linked Insurance Plan (UTI) / Dhanaraksha [LIC] :
Unit No. No. of Units Date Amount [Rs.]

5. Repayment of Loan for Purchase / Construction of New House :

DATE OF LOAN TAKEN TO BE
Location / Address of the Property
MENTIONED :

Total Loan Amt Principal Amt. Interest [Rs.] Total Amt. repaid during the year

6. Eligible Infrastructure Bonds / ELSS (Equity Linked Saving Scheme of Mutual Funds)
No. of Bonds. Certificate No./s Amount [Rs.]

7. Tution fee only in respect of children.

Receipt No. Recipt Date Amont [Rs.] for term Total

8. Fixed deposit for 5 years or more with a Scheduled Bank

D Rental Details : I am staying in company leased accommodation / [ Please Tick the correct
Rental Accommodation / Own Accommodation one]

In case rented, please give following details:

Name & Address of the Landlord Rent [Rs.] per month Period Total

E I confirm that the anove information is true and correct to the best of my knowledge and further
state that the investment made are out of my income chargeable to tax. Further I declare that the
incestments reffered to above are in my own name except Life Insurance Premium, PPF, ULIP,
if any in the name of my spouse / child and Cumulative Term Deposit in the name of my minor child.

F I am enclosing herewith a copy of proof of above savings / investments.

Date: Signature of the Employee:____________________________

Name : ___________________________________________

Please note that maximum rebate available for investment u/s 80C and 80CCC is restricted to Rs. 100000/- only