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I hereby declare that the following investments will be made by me during the period 1st April 2012 to 31st March 2013 Details of the Dependents Name of the Dependent
Relation
Age
House Rent
I am staying in a rented house and I agree to submit rent receipts or agreement with the land lord when required. If yes, House Rent per month paid Rs. _______________ x _____(months) 9,000 X 12 months Yes No Y
Amount
1,08,000 15,000
Medical Allownce
If I do not produce the bills to the extent of my eligiblity (maximum Rs.15000/- p.a) to the co., by 10th Feb 2013, then the company can consider the amount paid towards medical towards medical reimbursement for income tax purposes and deduct tax I agree Yes
26,400
Yes No
Date: Place:
16-Apr-12 Bangalore