Name of the Company Employee Name Employee PAN ID No.

NeilMed Devices Pvt Ltd Paritosh Karthick AVGPK1418B Emp# 63

I hereby declare that the following investments will be made by me during the period 1st April 2012 to 31st March 2013 Details of the Dependents Name of the Dependent

Relation

Age

House Rent
I am staying in a rented house and I agree to submit rent receipts or agreement with the land lord when required. If yes, House Rent per month paid Rs. _______________ x _____(months) 9,000 X 12 months Yes No Y

Amount

1,08,000 15,000

Medical Allownce
If I do not produce the bills to the extent of my eligiblity (maximum Rs.15000/- p.a) to the co., by 10th Feb 2013, then the company can consider the amount paid towards medical towards medical reimbursement for income tax purposes and deduct tax I agree Yes

Deduction under Chapter VI A

1. Sec 80 D - Medical Insurance Premium - Rs15000 for self and family, Rs.15000/- for dependent parents Rs. 20000/- if the dependent parents are senior citizens 2. Sec 80DD - Medical treatment / insurance of handicapped dependent - Rs.50000/Severe disability ( disability which is more than 80%) Rs 1,00,000/3. Sec 80DDB - Medical treatment (specified diseases only) Rs. 40,000/For senior citizen Rs 60,000/4. Sec 80E - Repayment of laon taken for Higher Education - Interest only - No limit 5. Sec 80G - Deduction in respect of donations to certain funds, charitable inst. Etc Donations above Rs.10000/- in cash will not be eligible for exemption. 6. Sec 80U - Self Handicapped Rs. 50,000/-, Severe disablility Rs 1,00,000/-.

Deductions under Section 80C

1. Life Insurance Premium /Pension Plan 2. Investment in Tax exempted Fixed Deposit for 5 years with a Scheduled Bank 3. Deposit in Public Provident Fund 4. Deposit in Post Office Savings scheme / NSC/ NSS 5. Interest on NSC Reinvested (upto 5th completed year only) 6. Investment in ULIP of UTI / LIC 7. Housing loan repayment - PRINCIPAL 8. Tution Fees towards Children's education 9. ELSS - Investment in Infrastructure bonds / Mutual Funds 10. Others (please specify) Pertol Bills Total Investment(Max Rs.100000/- .only)

26,400
Yes No

PREVIOUS EMPLOYMENT SALARY

Salary earned from 1st April 2012 till date of joining the company ( Tax computation Sheet at the time of Full and Final Settlement 0r From 16 to be attached)

INCOME OTHER THAN SALARY INCOME

I earn income from sources other than my salary If yes, Form 12C detailing other income is attached Yes Yes No No

DEDUCTION UNDER SECTION 24- HOUSING LOAN

Interest on Housing Loan - if self occupied then limited to Rs. 150,000/- amount Interest on Housing Loan - if let out then no limit NOTE: Form 12C along with the calculation of loss on house property needs to be attached for considering the above, please also specify the Pre-EMI interest paid during the previous years for consideration under loss from house property 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:

16-Apr-12 Bangalore

Signature of the employee