BOB Tech Solutions Pvt. Ltd.

Employee Declaration Form Tax Financial Year 1st April 2011 to 31st March 2012. Employee Tax Saving Investments / Expenditure Declaration Form Employee Name Employee No Department Designation PAN Gender

1. Rent payable by the employee towards residential accommodation Exemption under section 10(13A) Supporting Documents Month Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Amount (Rs) Month Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Amount (Rs)

2. Deductions from Gross Total Income: 2a.Deduction under chapter VIA: U/S 80C Particulars Contribution to PF Contribution to PPF NSC Contribution to Pension Fund Life Insurance Premium ULP of UTI / LIC Medical Reim U/S 80DD - Medical Treatment - physically handicapped dependent U/S 80 DDB - Medical Treatment for specified diseases 3. Details of Other sources of Income: 3 a. Income from House Property: (TO AVAIL THE TAX BENEFIT OF INTEREST PAYMENT TOWARDS FUNDS BORROWED FOR HOUSE CONSTRUCTION / ACQUISITION) Status of Property Self Occupied Let out property Deemed let out property Address of the property Date of capital borrowed Rent received (annual) If Let out Municipal Taxes Paid Interest paid for the current year Pre-construction interest paid details Amount (Rs) Supporting Documents must. Particulars House Loan repayment
PRINCIPAL AMOUNT ONLY

Amount (Rs)

Mutual Funds Infrastructure Bonds Child Education Fees Tuition fees only Any other investment

U/S 80 E - Education Loan Repayment U/S 80 G - Donations

U/S 80U - Physically Handicapped as specified

Address of the property TDS u/s 194I Enclose F.No. 16A, if TDS is Date of completion of acquisition / construction Please provide the aforesaid information in Form No. 12C 3b.Income from other sources: The details of any other income, if required to be considered by the employer for the purpose of withholding of taxes, to be provided in F.No.12B. Name and address of the previous employer Period of working Details of earnings & deductions I understand that the computation of total tax liability and the monthly withholding of taxes will be based on the completeness, accuracy of facts / information and the supporting documents made available by me. If any of the foregoing is not entirely complete/ inaccurate or not evidenced by adequate supportings, I hereby authorize my employer to proceed with further deduction of taxes as applicable under the provisions of the Income Tax Act and Rules. Further, I would be responsible for any tax / interest demand by the tax authorities, on account of improper / inadequate submissions of any information or documents.

Signature of the employee Place: Bangalore Date: To be filled in by the employer: The following facilities are provided to the employee Sl.No 1 Particulars of facility Company Leased Accommodation 1. Rent for premises 2. Rent for furniture & fixtures Motor car with / without driver 1.Cubic capacity of the car 2.Whether driver provided 3 Interest subsidy details 1.Eligibility as per Grade 2.The Interest payable by the employee Furniture & Fixtures at residence Club facility Credit card facility Any other facility Amount Supporting Documents

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