Confirmation regarding expenditure incurred on Medical Treatment

I, XXXXXX YYYYYYY ZZZZZZZ, Employee No. XXXX hereby confirm as under:

1) I have incurred the sum of Rs. 17,358 (Rupees Seventeen Thousand Three hundred and
Fifty Eight only) in the financial year 2014-15, on my medical treatment and/or treatment
on member of my family as defined under the relevant provisions of the Income Tax Act
1961.
2) The details of the expenditure are given below:
Particulars
Chemist Bills
Consultancy Bills
Pathological Bills
Dentist Bills
Family Doctor Bills
Any other expenditure
Total

Amount for the entire year in Rs.

755
1,601
15,002
17,358

3) I hereby further state that the aforesaid expenditure does not include the expenditure
reimbursed as per the medical insurance scheme of the company.
Date: 20-1-2015
Signature :

Note:

This declaration form is compulsory.

Thisform should be submitted at the end of each financial year or before
resigning/retiring
Please keep proper records of medical bills,doctor prescriptions or any other supporting
documentsetc.
The amount of allowance not actually spent as per the scheme would be taxed in the
hands of the employees.
Maximum exemption Rs 15,000/annum (Rs 1,250 x 12 months).