INVESTMENT PROOF SUBMSSION FOR THE YEAR 2017-2018 (For TDS purpose)

(APRIL 2017 TO MARCH 2018)

EMP Name EMP Code: PAN No

Contact No Office Landline Email

As per the provisions of section 139A (5A) of the Income-Tax Act it is mandatory for you to intimate your PAN to the Company
Residential Address (Please mention State & City)
Address: City:

State:

ACTUAL PAID TO BE PAID TOTAL

A. PARTICULARS OF INVESTMENT U/S. 80 C (Maximum of Rs.1,00,000) (APR-JAN) (FEB – MAR) AMOUNT RS.
1 Life Insurance premium paid for (Self / Spouse / Children) (a) Direct - LIC
2 Deposit in Public Provident Fund (Self / Spouse / Children) PPF
3 Contribution to Unit Linked Insurance Plan of LIC / UTI (Self / Spouse / Children) ULIP
4 Investment in infrastructure / telecom / power co. Equity Shares / Bonds
5 Investment in notified Equity Linked Saving Schemes ELSS
6 N S C (to be purchase during 01-04-13 to 31-03-2014)
7 Repayment of Housing Loan: Principal amount payable (April / March)
8 Contribution to Pension scheme (For Self Only)
9 Contribution to Retirement Benefit Unit Scheme of UTI
10 Children Education Allowance for two children (Tuition Fees only)
11 Term Deposit (for a period of not less than 5 years with a scheduled bank)
12 Other (please specify)

ACTUAL PAID TO BE PAID TOTAL

B. PARTICULARS OF INVESTMENT SECTION (APR-JAN) (FEB – MAR) AMOUNT RS.
Medical Insurance Premium
Up to Rs.15000 for normal person and Rs.20,000 in case any Senior
1 Citizen in your family member (U/s.80 D)

Expenditure on medical treatment of benefit of Handicapped dependent. (U/s

3 Rs.50,000/- or Rs. 1,00,000/- in case of severe disability. 80DD)
4 Repayment of interest on Loan taken for higher education (U/s.80E)
Exemption for physically handicapped (self) Rs.50,000 or Rs.1,00,000 in
5 case of severe disability (U/s.80U)
6 Others (please specify)

C. INTEREST PAYABLE ON HOUSING LOAN AMOUNT RS.

(I) Loan taken prior to 1 April, 1999 -Upto Rs.30,000

(II) Loan taken on or after 1 April, 1999 and acquisition /
Construction completed within 3 years from the end of Financial year in
which capital was
Borrowed - Upto Rs.150, 000 inclusive of (I) above
Apr May’17 Jun’17 Jul’17 Aug’17 Sep’17 Oct’17 Nov’17 Dec’17 Jan’18 Feb’18 Mar’18
’17

1. I hereby declare that the information given above is correct and true in all respects.

Signature of the employee

1 The maximum amount eligible for deduction u/s 80 C is Rs.1,00,000/-

2 Investment made / expenditure incurred is 100% deductible from salary income up to the amount mentioned.

3 If you have any income (other than salary, not being a loss under any such head other than the loss under the
head "Income from house property") you may, at your option furnish to payroll the particulars in Form 12C.

4 If you have received income from your past employer, you may report it to the Company in Form 12 B with a
copy of form 16 issued by your past employer.

5 If an employee is residing at different place other than his place of job, and if he has a property in his own
place, which is neither self neither occupied nor let out he is eligible to claim both HRA exemption and interest
on house property on providing a self-declaration.

6 For pervious employer income Form 12 B along with certified tax computation sheet issued by previous
employer should be submitted.

FORM 12C

INCOME FROM HOUSE PROPERTY

Period: April 2017 to March 2018

Name:

EMP ID:

Location of the House

Let out portion Self Occupied Total

Rental Income for the period (specify the

period)

Less: Taxes -Property tax/water tax etc.

Less: Repairs 30%of the Rental Income

earned

Income from House Property

Less: Interest Payable to (Bank) *

LOSS FROM HOUSE PROPERTY

Self Declaration Format for Join Loan

Employee Code -
Name of the Employee -
Date of Joining -

DECLARATION IN CASE OF SOLE OWNERSHIP AND JOINT-BORROWAL

(Attach Individual Declarations for more than one Borrower(s))

I Mr / Mrs. ____________________________________ hereby declare that I am claiming _________%

(Specify percentage of benefit claimed (or) NIL) of the benefit arising out of Interest and Principal on the Loan

account No(s) ______________________________________taken from _________________________

(Institution Name) for the property

__________________________________________________________________________________(Address

of the property) in my own return of Income.

Amount Claimed by the Employee - Rs. ___%

Amount claimed by Co-borrrower - Rs. ___%

Total as per Interest Certificate - Rs.

Signature of the co-borrower: (To be signed over an one rupee revenue stamp)

“Form No. 10-IA

[See sub rule(2) rule 11A]
Certificate of the medical authority for certifying ‘person with disability’,
‘severe disability,’ ‘autism’, ‘cerebral palsy’ and ‘multiple disability’ for
purposes of section 80DD and Section 80U
Certificate No.___________________
Date._________________

This is to certify that

Shri/Smt/Ms_________________________________________
Son/daughter of Shri__________________________________age___years
Male / female residing at
________________________________________________
_________________________________________________ Registration
No. _____________________ is a person with disability/severe
disability*suffering from autism/cerebral palsy/multiple disability*.

2. This condition is progressive/non-progressive/likely to improve/not likely

to improve*.

3. Reassessment is recommended/not recommended after a period of

_____________
months/years*.
Sd/-
(Neurologist/Pediatric Neurologist/Civil surgeon/Chief Medical Officer*)

Name:Address of institution/government hosipital:

---------------------------------------------------------------------------------------------
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Qualification/designation of specialist:

SEAL

Signature/Thumb impression*of the patient

Note: * Strike out whichever is not applicable.”

RENT RECEIPT
Tenant Name :

Residential Address:

City & State :

Landlord PAN :

Sl No Month Rent Per Month (Rs)

1 APR'17
2 MAY'17
3 JUNE'17
4 JULY'17
5 AUG'17
6 SEP'17
7 OCT'17
8 NOV'17
9 DEC'17
10 JAN'18
11 FEB'18
12 MAR'18
TOTAL

Landlord Signature: Affix Rs.1/-

Revenue
Stamp
Date:

Place:

Note: - House owner (Landlord) PAN number is mandatory, if rent paid exceeds 100000
per annum.

Employee Self-declaration

I do hereby declare that I will be responsible for any and all taxes arising out of this benefit in current as
well as in future legislation.

Emp ID –

Emp Name –

Employee Signature -