Form of Employee Declaration for the period April 2010 to March 2011

Name of the Employee:

Address:

Date of Birth:
Employee Code:
PAN
Gender:

CTC (per annum)

CTC is composed of following:
Basic Salary (per annum) -
Bunch for Allowances and perquisites -

The employee can choose any of the following:

Maximum
Opted? Conditions
Limit
a) House Rent Allowance No - Must produce Rental Agreement or Rent Receipt
b) Transport Allowance Yes 9,600 No conditions, recommeded to opt for
c) Children Education Allowance Yes 2,400 Must produce School Fee Receipt
d) Children Hostel Allowance Yes 7,200 Must produce Hostel Fee Receipt
e) Medical bills reimbursement Yes 15,000 Must produce Medical bills
f) Telephone (landline including broadband) bills
No - Must produce Bills
reimbursement
g) Mobile bills reimbursement No - Must produce Bills
h) Leave Travel Concession No - Must produce Bills
i) Food/sodexo coupons No - Not taxable for employee
j) Others No -
Total 34,200

Investment & Payment Declaration

Amount
a) Investments under section 80C
(Ex: LIC, PPF, Mutual fund, Term Deposit, etc)
b) Contribution to Pension Fund under section 80CCC
c) Medical Insurance Premium u/s 80D
Self
Parents
d) Medical Treatment of Handicapped Dependent
u/s 80DD
e) Medical Treatment of Specified Disease u/s 80DDB
f) Interest on educational loan u/s 80E
Max Limit Conditions
100,000 Must produce the proof of investment
- 15,000 Additional 5000 incase of Senior Citizen
15,000 Additional 5000 incase of Senior Citizen
50,000 Must produce medical certificate
40,000 Must produce medical certificate
No limit Must produce bank certificate
g) House Rent payable - No limit Must produce Rental Agreement or Rent Receipt
h) Housing Loan interest payable - 150,000 Must produce bank certificate
 Prepared by B.C.Shetty Co, Chartered Accountants, Bangalore.

Tax expert: Fill the

name of the company

Address:

Employee Income Tax Declaration Form for the Year 2010-11

EMPLOYEE ID *
EMPLOYEE NAME Children
GENDER ###
PAN ###
Address of Employee ###

Father's Name
Date of Birth
Residential Status
Phone Number
Name of the Bank
Bank Account No.
Type Of account
MICR No
No. Of Children
A. Rent paid details for claiming HRA exemption Rs Per Month
Serial No From Date
To Date
City

B. Deductions from income tax Rs per Annum

1 Medical Insurance Premium(U/S 80 D)
2 Medical Insurance Premium(U/S 80 D) For Seior Citizen
3 Medical Treatment/ Handicapped Dependent (U/S 80DD) <80% Disability
4 Medical Treatment/ Handicapped Dependent (U/S 80DD) >80% Disability
5 Medical Treatment Of Specified Diseaes Only (U/S 80DDB)
6 Medical Treatment Of Specified Diseaes Only (U/S 80DDB) For Senior Citizen
7 Interest On Education Loan (U/S 80E)
8 Donations to the certain fund under 80G, deduction
9 Permanent Physical Disability (80U)
10 Permanent Physical Disability Severe Disability (80U)
C. chapter-VIA- total amount of deduction allowed is Rs.100000
10 Contribution To Pension Fund (U/S 80CCC)
11 Life Insurance Premium
12 Public Provident Fund (Ppf)
13 National Savings Certificate (Nsc)
14 Nsc Interest
15 Children Education Fee
16 Mutual Funds / Ulip
17 Investments In Term Deposits(Period Of 5 Yrs Or More) In A Scheduled Bank
18 Deposit In Post Office Tax Saving Scheme
19 Eqity Linked Savings Scheme(Elss)
20 Housing Loan-Principal Amount Repayment Only
21 Fixed Deposits
D. Loss From House Property
Address Of The Property Against Which Loan Taken

Residential Status- Self- Occupied/ Letout

Total amount of interest paid (Post construction/ possession) during the financial
year(April 10 to march 11)
Limited to Rs.30000.00 if loan wa availed before 01/04/1999
Limited to Rs.150000.00 if loan was availed after 01/04/1999
Annual Renal Value
Municipal Tax paid
E.Other income
Bank Interest
Gain from Securities Trading
Other incomes if any
Other Income Declaration To Be Accounted For Tax Calculation
F. Previous employer income details- form-16 or signed tax computation
sheet from previous employer along with form 12B is mandatory
Salary Paid By The Previous Empoyer After Sec 10 Exemptions
Profession Tax Deducted By The Prvious Employer
Income Tax Deducted By The Prvious Employer
G. Exemptions Against Bills Rs Per month
Medical Reimbursement
Food Coupons
Telephone and Broad Band expenses
LTA Reimbursement
H. Allowance-exempted Rs Per month
Education Allowance
Hostel allowance
travell allowance
Conveyance allowance

Mandatory
Declaration
1) I Hereby Declare That The Information Given Above Is Correct And True In All Respects.
2) I Also Undertake To Indemnify The Company For Any Loss/ Liability That May Arise In The Event Of The Above Information
Being Incorrect.

Date
Place
Signature
1)

2)

3)

4)

5)

6)
 Notes:

Proof as required above must be submitted to the company before 31st January 2011, otherwise all the exemptions
and deductions shall be ignored and tax will be collected.

Income Tax of the employee shall be computed after receipt of this declaration and Take home pay shall be
determined.

Following should be in the name of employee:

Rental agreement or Rent Receipt
Telepone Bills
Mobile Bills
Travelling Bills
Bank Certificate for Interest

Medical bills should be in the name of Self, spouse, children and parents, brothers, sisters of the employee
who are dependent on the employee.

For Investment or Payments u/s 80C, Receipts of the following to be submitted

> LIC premium paid receipts (only self, spouse, child are eligible)
> Term Deposit Receipt: Amount deposited in a FD for 5years or more with a scheduled bank
> Tuition Fees Receipt: (Maximum of 2 children) Does not include any payment towards deveopment fees/donation/any oth
payment at the time of admission or otherwise to any University/College/Educational instution
> Proof of investment in Mutual Funds or unit Linked Insurance Plan of UTI/LIC Mutual Funds

For availing exemption u/s 80D, the Mediclaim policy should be on the health of Self, spouse, parents & children