ADANI POWER LIMITED

INCOME TAX DECLARATION FOR FINANCIAL YEAR 2009-2010

Employee Code 30001124

Employee Name MANAV SHAH
Designation / Dept. OFFICER / ACCOUNTS
Permanent Account No.
CONTACT NO. 9426600882 EXTN. : 57105

Declaration for Investments u/s 80-C

I hereby confirm that I have invested/will be investing the following for the purpose of claiming
deduction under Income-Tax Act from my Salary Income for the Financial Year 2009-2010.
Particulars u/s 80C: Proposed Actual
Amount of Amount
Investment Invested
1. LIC Premium (Self, Spouse, Children)
2. P.P.F ( Self, Spouse, Children)
3. National Saving Certificate (NSC)
4. Accrued Interest on NSC (give details)
5. ULIP
6. Housing Loan repayment (only principal) (Certificate from
Bank/Institution Required)
7. Infrastructure bond
8. Tution Fees (Max. Two child tution fees allowed per year)
9. Mutual Funds
10. Pension Plan (80-CCC)
11. Others (Please Specify)

Total
Others Details
Housing Loan Interest (Certificate from Bank/Institution
Required)

Particulars u/s 80: Proposed Actual

Amount of Amount
Investment Invested
1. Medical Insurance Premium u/s 80D 5559 5559
2. Interest on Education Loan (self/spouse/children) u/s 80E

Declaration of Rent:

Accomodation Type : a. Own House ______ b. Rented House ___√_______

c. Rent Free Accomodation provided by Co. ________

Pl. mark √ or X for housing status. If rented house, then submit monthly house rent receipts.
(revenue stamps duly affixed) with details of rent amount/name & address of landlord, address
of rented house.
1 Rent Per Month 3000
2 Total Months 12
3 Total Rent for FY 2009-10 36000

If Rent free accommodation is provided by the Company, where Co. is making rent payment, the
required details are to be provided duly verified by HR / Admin. Dept.
Declaration for Transportation Allowance:
I declare that I have spent/ will spend Transportation Allowance received by me for the purpose
of commuting between my residence to office place and back.

Declaration for Medical Reimbursement: Amount of Medical Bills to be submitted:

I declare that I will spend Medical allowance received by me for the purpose of Medical expenses
of my self, spouse, dependent parents and children and part of the allowance not spent by me may
be treated as taxable.

Medicals Bills are submitted in the Format as per “Annexure M” attached

VERIFICATION
I hereby declare that what is stated above is correct. I undertake to inform Accounts department
of any change in the above facts.

I hereby confirm that I shall submit necessary proof of Investment under Chapter VI- A/Medical
bill, rent receipts, etc. for FY 2009-10, failing which the relief computed may be withdrawn.

___________________________
Signature of the Employee Date:________

Important Note: Please note that any Income Tax liability arising out of a wrong declaration will
be the responsibility of the employee concerned.
 ADANI POWER LIMITED

INCOME TAX DECLARATION FOR FINANCIAL YEAR 2009-2010

ANNEXURE -M
Declaration for Medical Reimbursement: Amount of Medical Bills to be submitted:

I declare that I will spend Medical allowance received by me for the purpose of Medical expenses
of my self, spouse, dependent parents and children and part of the allowance not spent by me may
be treated as taxable.
Following are the summary of bills attached.
Name of the Medical Store /
Sr. No. Bill No. Date Hospital Amount
AROGYANIDHI MEDICAL
1 3777 4/4/2009 STORE 221
11/4/200 AROGYANIDHI MEDICAL
2 3878 9 STORE 30
20/04/20 AROGYANIDHI MEDICAL
3 3994 09 STORE 216
24/04/20
4 496 09 TANARIRI MEDI 122
30/04/20 NEW BHAGWATI
5 874 09 MEDICINES 695
6 10637 7/5/2009 SHREE SEVA MEDICAL 200
7 10636 7/5/2009 SHREE SEVA MEDICAL 181
8 10662 8/5/2009 SHREE SEVA MEDICAL 68
14/05/20
9 18178 09 D.NARANDAS & SONS 115
30/05/20
10 11580 09 SHREE SEVA MEDICAL 429
11 8164 8/5/2009 MRUGA MEDICINES 33
13/05/20
12 2457 09 ASHIRWAD MEDICINES 263
13 3427 1/6/2009 ASHIRWAD MEDICINES 235
10/6/200
14 10944 9 SHREE SEVA MEDICAL 145
11/6/200
15 4038 9 ASHIRWAD MEDICINES 267
23/06/20
16 560 09 ANAND CHEMIST 480
26/06/20
17 4928 09 ASHIRWAD MEDICINES 360
26/06/20 AROGYANIDHI MEDICAL
18 4859 09 STORE 166
AROGYANIDHI MEDICAL
19 4956 3/7/2009 STORE 284
11/7/200
20 698 9 SHREE SEVA MEDICAL 247
21 1179 3/8/2009 SHREE SEVA MEDICAL 310
22 30436 25/08/20 MRUGA MEDICINES 205
 09
30/08/20
23 31643 09 MRUGA MEDICINES 160
20/09/20
24 36416 09 MRUGA MEDICINES 185
24/09/20
25 2730 09 SHREE SEVA MEDICAL 192
28/10/20 AROGYANIDHI MEDICAL
26 522 09 STORE 165
10/1/201
27 3837 0 AHMEDABAD MEDICAL 450
TOTAL 6424

___________________________
Signature of the Employee Date:________