To : Mr.

Yuvraj D Sankpal Mumbai Head Office

Financial Year : 2013-14 Assessment Year : 2014-15 Sub: Income tax declaration of direct savings for the F/Y 2013-14

From: (Name) Employee Code No. Permanent Account No. Mobile No. / Residential Tel No. Residential Address:

I hereby declare that the following amounts are / would be paid / invested by me during the Financial Year ending 31st March 2014, which please be taken into account for computing Income-tax payable by me during the said year. 1. Life Insurance Premium paid in respect of policies taken on own life / on the life of wife / husband or on life of any minor children as the case may be as detailed below: Total Amount of Policy No. Sum Assured Type of Policy S. No. Premium
Direct Payment

1 2 3 4 5 6 2. National Saving Certificates (VIII Issue) purchased / to be purchased during the period April 2013 to March 2014 (Certificates should be in the name of self) as detailed below: S. No. Certificate No. Date of Purchase Amount (Rs.) 1 2 3 3. Subscription to Public Provident Fund Scheme, 1968 as detailed below: PPF A/c. No. Name of the A/c. Holder 1 2 4. Tuition Fees paid / to be paid to School / College for Children (maximum 2 children) Name of School / College Name of the Children / Institution 1 2 Amount (Rs.)

Amount (Rs.)

5. Unit Link Insurance Premium paid / to be paid to UTI during the period from April 2013 to March 2014 Total premium (Rs.) Policy / Membership No. Date of Payment 1 2 3 6. Fixed Deposit for 5 years or more with a Scheduled Bank or any other Tax Saving Investment: Period Fixed Deposit Receipt No. Amount (Rs.) Date of Purchase 1 2 7. U/S 80CCC - Premium paid / to be paid under Pension Scheme Name of Company 1 2 8. U/S 80D - Mediclaim premium (maximum allowed Rs.15,000/-): Policy No. Sum Assured 1 2 Sum Assured Date of Purchase
Total Premium (Rs.)

Total Premium (Rs.)

9. Interest paid on Housing Loan u/s. 24(1) (Vi) during the period from April 2013 to March 2014 (to consider this amount, provisional statement of the Financial Institution from where housing loan is taken to be attached): Total amount of Principal and Name of the Finance Company / Date of possession of the Interest paid / to be paid during Bank & the date of Loan made said house the F/Y Financer: Principal (Rs.): Interest (Rs.): Date of Loan:

10. Rent paid - Eligible for exemption u/s 10 (13A): I am in receipt of monthly House Rent Allowance and residing in a rented house (which is not owned by me) and I pay monthly rent as per the attached receipts. Total Rent paid / to be paid for the Name and address of the Landlord Address of the rented house period April 2013 to March 2014 1 Note: From This Year Onwards If You Are Claiming For Exemption On House Rent Make Sure To Forward Us The Registered Agreement Copy Along With The Pan Card Copy Of The Landlord. I declare that the particulars furnished by me are true and correct to the best of my knowledge and belief.

Name : Employee No.: Mobile No. / Residential No. With STD Code : Place: Date: [ Present Job Site No.] Signature

Note: All are requested to furnish the above declaration immediately, by 25/06/2013 so that the tax (if any) can be deducted proportionately to comply with the provisions of the I. Tax Act.