INCOME TAX DECLARATION FORM

Name of the Employee Emp Id PAN Address

Financial Year Asst Year

2010-2011 2011-2012

Details of Rent Paid per month Address Investment u/s 80CCC Investment u/s 80 D Investment u/s 80C a) LIC Premium b) Public Provident Fund c) National Savings Certificate d) Tax Savings Bonds e) Any other qualifed Investments i)ELSS ii)ULIP iii) Details of Housing Loan: Principal Amount Interest Amount Details of Income in Previous Company ** Gross Total Income Tax Deducted at Source (TDS) Net Total Income Note: A) Please furnish the proofs of Investment before 20th September 2011, failing which the tax will be deducted without considering the investment plan. B) Permanent Account Number is must for all employees, failing which Form 16 or any other document relating to employee salary cannot be issued **C) Please attach Form -16 of your previous employer, if joined after 1st April, 2011

Signature Name of the Employee Date