Employee No.________________________________ PAN : _______________________

(As per salary slip)

Employee Name:______________________________ Location:_______________________________

Department:______________________________ Designation:_______________________________

No. of Children: ______ No. of Dependants: _______

Amount

1 Life Insurance Premium (For Self, Spouse and Children only) max. limit Rs.100,000/-

2 Public Provident Fund (For Self, Spouse and Children only) max. limit Rs.1,00,000/-

3 National Savings Certificates (For Self only) max. limit Rs.100,000/-

4 Interest on National Savings Certificates (max. limit Rs.100,000/-)

5 Unit Linked Insurance Scheme- eligible for deduction U/S 80C (max. limit Rs.100,000/-)

6 ELSS ( Equity Linked Savings Scheme) - eligible for deduction U/S 80C (max. limit Rs.100,000/-)

7 Mutual Funds- eligible for deduction U/S 80C (max. limit Rs.100,000/-)

8 Children Education Fees (maximum of 2 children) (max limit Rs.100,000/-)

9 Pension Plan ( U/S 80 CCC) (max. limit Rs.100,000/-)

10 5 year Fixed Deposit with Scheduled Bank (max. limit Rs.100,000/-)

11 5 year Post Office Time Deposit Account (max. limit Rs.100,000/-)

12 Senior Citizen Saving Schemes (max. limit Rs.100,000/-)

14 Others (Please Specify)

Amount

1 Section 80D Mediclaim ( Please Refer Instructions for details)

2 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 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.

5 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.

6 Others (Please Specify)

Amount

1 (i) Date of Sanction of Loan : (ii) Under Construction ( ) / Self Occupied ( )

2 Housing Loan - amount payable towards Principal (max. limit Rs.100,000/-)

3 Housing Loan - amount payable towards Interest (max. limit Rs.150,000/-)

4 Address:

1

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

Benefit for Housing Loan Interest will be allowed only if the property is fully constructed and is in possession of the Employee

[C] HOUSING LOAN DETAILS U/S 24(2) FOR INTEREST & 80C FOR PRINCIPAL

[D] DECLARATION OF HRA U/S 10(13A) (read with Rule 2A) FOR FINANCIAL YEAR 2012-2013

Details of Rental Accomodation

SBI GENERAL INSURANCE COMPANY LIMITED

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)

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)

[B] DEDUCTION UNDER SECTION 80D / 80DD / 80DDB / 80E / 80U OF THE INCOME TAX ACT

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Amount

1 Gross Income ( Gross Salary, Perks & Other Income Less: exemption U/S 10 for HRA,Conveyance etc.)

2 Provident Fund deduction - own Contribution

3 Professional Tax deducted

4 Income Tax / TDS deducted

Amount

1 Total Gratuity Exemption

2 Total PL Encashment Exemption

3 Any LTA Exemption taken in current two year block i.e. 2010-2011

Amount

1 Interest earned from Bank Savings

2 Interest earned on Maturity of Fixed Deposit

3 Any Other Income

4 Loss from Sale of House Property (If any, please mention here. Computation required)

SR. NO. DATE OF BIRTH RELATION WITH EMPLOYEE

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.

_____________________________ ________________

Employee Signature Date

[F] EXEMPTIONS TAKEN FROM PAST EMPLOYERS

[G] ANY INCOME EARNED OTHER THAN SALARY

[H] DETAILS OF DEPENDANTS

NAME OF DEPENDANTS

[E] PREVIOUS EMPLOYER SALARY DETAILS for F. Year 2012-2013 ( Attach Salary Certificate)

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