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DECLARATION REGARDING LIC POLICY / PPF

I,.. (Name of the Spouse), do hereby confirm that


the following LIC Policy / PPF which is in my name have being paid by my husband / wife
.. (Name of the Employee) in the Financial Year 2016-17.
Sl. No.

Policy No. /
PPF Account No.

Date of Payment

Amount (INR)

Total
I further confirm that I do not claim the above said policy / PPF for Income Tax exemption in the
Financial Year 2016-17

The above information is true and correct to the best of my knowledge and I shall be personally
responsible and liable if the same is found to be incorrect.

Signature.

Name : Spouse Name


PAN : Spouse PAN

Place :
Date: