Form 16

UNIT: INCOME- TAX DECLARATION FORM FOR THE FINANCIAL YEAR 20132014

EMP NAME
:
EMP CODE :
DEPT
:
E-MAIL ID
:
PAN NO
:
MOBILE NO
(Each employee compulsorily has to give PAN.NO.)
Present Address

: ___________________________________________________________
___________________________________________________________
____________________________________________________________
____________________________________________________________
___________________________________________________________

No of school/college going children

____________
A ) INVESTMENT QUALIFYING FOR DEDUCTION U/S SEC 80 C & 80 CCC
DESCRIPTION
Amount Invested (Rs.)
1. LIC premium (DIRECTLY PAID BY EMPLOYEE)
2. ULIP premium to UTI
3. Purchase of NSCS
4. Principal Repayment of Housing loan
5. Contribution to Pension scheme.
6. Tuition fees (donation, development fees etc not eligible)
7. Interest in NSC (up to 5th completed year only)
8. 5 years fixed deposit in scheduled bank
9. Deposit in post office savings scheme.
10. Mutual funds
11. Public Provident Fund
Total (Maximum Rs. 1,00,000)
Rs._________________________
Note: Details of deduction made from salary in respect of PF, LIC, -Salary
saving scheme, MEDICALIM will be taken from the payroll data .
B)

DETAILS OF RENT PAID : (FOR CLAIMING EXEMPTION u/s 10(13A)

Address:

PAN NO _______________________OF THE LANDLORD IF THE RENT PAID IS MORE

THAN
RS.100000/- (ONE LAKH)
Further if annual rent paid by the employee exceeds Rs 1,00,000 per annum,
it is mandatory for the employee to report PAN of the landlord to the
employer. In case the landlord does not have a PAN, a declaration to this
effect from the landlord along with the name and address of the landlord
should be filed by the employee.
Rent paid details:
Month
(Rs)

Rent Paid (Rs.)

April 2013
May 2013
June 2013
July 2013
August 2013
September 2013

Month

Rent Paid

October 2013
November 2013
December 2013
January 2014
February 2014
March 2014

Note: Benefit of HRA will be given only on the basis of Valid Rent Receipts. Rent
receipts to contain date of receipt, Name and Address of the Land Lord, Month/Period
of Rent, Name of the tenant (employee), and mode of payment.
C) DECUCTION FROM TOTAL INCOME ON THE FOLLOWING
CONTRIBUTION/EXPENDITURE
SECTION
AMOUNT (RS)
80 D
80DD
80DDB
80U
80E
80G
24(1)

PARTICULARS
In respect of medical Insurance premium
In respect of medical treatment of a handicapped
Dependant from physical disability/mental retardation)
Deduction in respect of medical treatment
Deduction in respect of permanent disability
Interest on repayment educational loan
Donations
Declaration of interest on repayment of Housing loan

Loan taken from

Date of acquisition/

Interest paid

Proof attached
Construction of property
(yes)/No

No benefit will be given if the date of acquisition/construction of property is not given.

In case of self occupied property the maximum loss (interest) allowed will be restricted
to Rs.1,50,000/- .
The benefit, loss on house property will be given only on the basis of valid form 12C
signed by the employee.

The above information is to be considered for estimating my Income tax

liability for the financial year 2013-14

I certify that the payment listed above will be made by me out of my income
chargeable to income tax during the financial year. Necessary documents in support
of these investments are enclosed/will be submitted on or before 20TH February 2014.
DATE:
SIGNATURE:_____________________