SBI GENERAL INSURANCE COMPANY LIMITED

Employee No.________________________________ (As per salary slip) Employee Name:______________________________ Department:______________________________ No. of Children: ______ PAN : _______________________

Location:_______________________________ Designation:_______________________________ No. of Dependants: _______

INVESTMENTS PROOF SUBMISSION FORM FOR - FINANCIAL YEAR 2012-2013

[A] INVESTMENTS FOR DEDUCTION UNDER SECTION 80C OF THE INCOME TAX ACT,1961(Limit Rs.1,00,000) 1 2 3 4 5 6 7 8 9 10 11 12 14 Life Insurance Premium (For Self, Spouse and Children only) max. limit Rs.100,000/Public Provident Fund (For Self, Spouse and Children only) max. limit Rs.1,00,000/National Savings Certificates (For Self only) max. limit Rs.100,000/Interest on National Savings Certificates (max. limit Rs.100,000/-) Unit Linked Insurance Scheme- eligible for deduction U/S 80C (max. limit Rs.100,000/-) ELSS ( Equity Linked Savings Scheme) - eligible for deduction U/S 80C (max. limit Rs.100,000/-) Mutual Funds- eligible for deduction U/S 80C (max. limit Rs.100,000/-) Children Education Fees (maximum of 2 children) (max limit Rs.100,000/-) Pension Plan ( U/S 80 CCC) (max. limit Rs.100,000/-) 5 year Fixed Deposit with Scheduled Bank (max. limit Rs.100,000/-) 5 year Post Office Time Deposit Account (max. limit Rs.100,000/-) Senior Citizen Saving Schemes (max. limit Rs.100,000/-) Others (Please Specify) [B] DEDUCTION UNDER SECTION 80D / 80DD / 80DDB / 80E / 80U OF THE INCOME TAX ACT 1 Section 80D Mediclaim ( Please Refer Instructions for details)
Restricted to max of Rs.15000 for self / spouse / dependents children. Additional, max of Rs.15000 for parents if parents are senior citizen then it is max 20000)

Amount

Amount

Section 80 DD (Maintenance/medical treatment for handicapped dependents.) (Max limit of Rs.50,000/- in case of normal disability & 1,00,000/- in case of severe disability)
Note: Form 10IA from Medical Authorities in prescribed form & manner is Mandatory.

4 5

Section 80 E (Repayment of interest on loan for higher education for Self, Spouse and Children only)
Note: Attach Provisional certificate from Bank or Financial Institution.

Section 80 U (Deductions in case of self being totally blind or physically handicapped.)

Limit: Rs.50,000/- in case of disability or Rs.100,000/- in case of Severe Disability(80% or more) Note: Form 10IA from Medical Authorities in prescribed form & manner is Mandatory.

Others (Please Specify) Amount ) / Self Occupied ( )

[C] HOUSING LOAN DETAILS U/S 24(2) FOR INTEREST & 80C FOR PRINCIPAL 1 2 3 4 (i) Date of Sanction of Loan : (ii) Under Construction (

Housing Loan - amount payable towards Principal (max. limit Rs.100,000/-) Housing Loan - amount payable towards Interest (max. limit Rs.150,000/-) Address:
Benefit for Housing Loan Interest will be allowed only if the property is fully constructed and is in possession of the Employee

[D] DECLARATION OF HRA U/S 10(13A) (read with Rule 2A) FOR FINANCIAL YEAR 2012-2013 1 Details of Rental Accomodation Name of Landlord: ______________________________________________________________________ 2 PAN No. of Landlord: ______________________ City: ____________________________________

Address: ________________________________________________________________________________ 3 Rent Payable during the Financial year 2012-2013 Amount Per Month

Note:

PAN No. of land Lord is mandatory if Monthly rent is => 15000

At the time when we ask for the actual proof , we wolud required 12 month rent receipt or lease Agreement

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[E] PREVIOUS EMPLOYER SALARY DETAILS for F. Year 2012-2013 ( Attach Salary Certificate) 1 2 3 4 Gross Income ( Gross Salary, Perks & Other Income Less: exemption U/S 10 for HRA,Conveyance etc.) Provident Fund deduction - own Contribution Professional Tax deducted Income Tax / TDS deducted [F] EXEMPTIONS TAKEN FROM PAST EMPLOYERS 1 2 3 Total Gratuity Exemption Total PL Encashment Exemption Any LTA Exemption taken in current two year block i.e. 2010-2011 [G] ANY INCOME EARNED OTHER THAN SALARY 1 2 3 4 Interest earned from Bank Savings Interest earned on Maturity of Fixed Deposit Any Other Income Loss from Sale of House Property (If any, please mention here. Computation required) [H] DETAILS OF DEPENDANTS SR. NO. 1 2 3 4 5 DECLARATION
I hereby declare that what is stated above is true & correct. I undertake to notify you immediately of any change in the above facts. Any Income Tax liability arising out of wrong declaration will be my responsibility, and I undertake to indemnify the Company & its officers from all consequences, monetary and otherwise, arising out of any incorrect and/or incomplete information provided in this declaration.

Amount

Amount

Amount

NAME OF DEPENDANTS

DATE OF BIRTH

RELATION WITH EMPLOYEE

_____________________________ Employee Signature

________________ Date

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