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<Name of the Company>

Tax Savings Declaration For The Year April 2010 To March 2011

Employee Code :
Employee Name :
Department :
PAN No.
The following Investments will be made by me during the Period April 2010 to March 2011

Particulars Max. Limit Amount

House Rent Paid


House Rent paid

Restricted to
your Annual
LTA Eligibility

Deduction under Section 24


Interest on Housing Loan

Deduction Under Chapter VI A


1 Sec 80CCC - Contribution to Pension Fund (Jeevan Suraksha)
2 Sec 80D - Medical Insurance Premium
3 Sec 80DD - Medical treatment/insurance of handicapped dependant
4 Sec 80DDB - Medical treatment (specified diseases only)
5 Sec 80E - Interest on repayment of Loan taken for higher education
6 Sec 80U - Handicapped

7 Sec 80C
7.1 Life Insurance Premium (other than salary deduction)
7.2 Deferred Annuity
7.3 Contributions to statutory provident fund / recognized provident fund
7.4 Public Provident Fund
7.5 Deposit in NSC
7.6 Interest on NSC reinvested (upto 5th completed year only)
7.7 ULIP of UTI/LIC
7.8 Principal Loan (Housing Loan) Repayment
7.9 Mutual Funds
7.10 NHB Scheme (housing loan account scheme / pension fund)
7.11 Tuition fees for full time education for children
7.12 Investment in Infrastructure Bonds (as specified in section 80C)
7.13 FD with scheduled bank for 5 years or more
7.14 Deposit in post office under five year time deposit scheme
7.15 Others (please specify)

Note: Maximum deductible under sections 80C & 80CCC cannot exceed Rs.1 lacs + 20,000 additional for
infrastructure bonds

Previous Employment Salary (For New joinees only)

Note: Please note that income (previous employment) can only be taken
based on declaration(Form 12B). No benefit for deductions like
PF,Profession Tax, Income Tax deducted at source can be given unless
Form 16/Tax Certificate from previous employer is attached.
Signature of the Employee
Note: PAN is mandatory for all employees without which Form -16 can't be issued. If you don't have the
PAN please initiate the PAN application process.

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