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Axcend Automation and Software Solutions Pvt. Ltd.

Declaration for Investments / Other Income / Losses

Employee Name:- P.SRIVATSAN

Employee No:-0297

Designation:- Technical Consultant HR Grade:- D

Sex:- Male

Sl. No.

1

Particulars of Income / Investments / Losses

Declared Amount

per Annum

Income from House Property/Loss from house property(Indicate Loss within brackets in the declaration)

2

3

4

a

b

c

d

e

f

g

h

i

j

k

5

6

Income from Other Sources during April 12 to March 13

Rent Paid per month

Rs 5500/ Month Rs 66000/Year

Savings u/s 80 C of Income Tax Act like LIC premium, Tuition Fees, PPF, NSC, Recognised Mutual Funds, 5 years Fixed Deposit, Home loan principal payment etc.

As per details given below subject to a limit of Rs. 1 Lakh U/s 80C

Policy No.719916814- 8.5 - 179-12, Amt-11788 Policy No.719916813- Plan - 149-15,Amt-15852

Life Insurance premium paid on self / spouse / children

Contribution to Public Provident Fund ( Max Rs 1,00,000)

Investment in NSC

Contribution to UTI for participating in ULIP

Repayment of Housing Loan (principal amount)

Accrued interest on NSC (Please state the amount of accrued interest)

Education expenses/Tution fees of children,

Approved Mutual Fund/bonds

for two children

Fixed deposit with Scheduled Bank (for a period of 5years or more)

Contribution to Pension Scheme of LIC or any other approved Insurance Co.

National Pension Scheme

Long Term Infrastructure bond u/s 80 CCF (Max Rs.20,000)

Medical Insurance Premium for Self and dependents u/s 80 D including cost of health check up plans (Rs.5000 limit)

7

8

9

10

Interest paid on Education loan for self only u/s 80 E

Any Claim for Permanent Physical Disability u/s 80 U

Income from Previous employer to be considered for employees joining after 1st April 2012

Any Other Details Specific relating to Tax deduction

Period From APR 2012

Period To MAR 2013

HR Grade:- D

PAN:-CVCPS2747B

REMARKS

In case of home loan interest on self occupied property to be declared in this section. Limit for exemption Rs.1,50,000 p.a. for interest paid.

Declare any other income you would like the

company to consider for tax deductions. No proof needed for this.

Give 3 months receipt as proof

Insurance Policy on Parents not allowed u/s 80 C

Self, Spouse and Children allowed

Self, Spouse and Children allowed

Tution fees to College/University/Institute paid

For Self max Rs.15,000/- and dependents

Rs.5,000/- Allowed on policy taken on a Senior

Citizen of 65 years or older. Cost of helath check up for Rs.5000/- allowed Only Interest for self for higher education

allowed.

Proof as required under Income Tax Rules to be provided

Proof by means of an attested statement of

salary and deduction or Form 16 to be provided

Declaration :

I am aware that I shall submit the proof for the above on or before the due dates failing which the

Company will deduct tax at source from my Salary without considering the declaration for those items

for which proofs are not given.

Signature

Name _P.SRIVATSAN_ Date _16-04-2012

Due Date for submission : 16 Apr 2012 (For New employees, before first salary cycle)