0. Financial year: 2012-2013 2013-2014 2014-2015

1. Name

2. Designation:

3. PAN/GIR Number:

4. Have you got any income other than salary, like income from house property, capital gains, interest/dividend from investments, income from other sources?
   If so, state the amount of annual income:

   (a) In case of income from house property
        (i) Location of House
   
        (ii) Amount of rent received per annum after admissible deduction
   

   (b) Income from other sources

   Total:

5. If you are in receipt of H. R. A.

   (a) Particulars of house taken on rent

   (b) Amount of house rent paid per annum (Please attach rent-receipt from house-owner in case HRA received is more than Rs. 3000/- P.M.)

6. Do you claim any deduction under Chapter VI-A of the Act. If so, state the amount of deduction claimed. Necessary certificate from competent authorities, whenever required, may be attached.

   (a)80 D

   (b)80 DD

   (c)80 DDB

   (d)

   (e)

   (f)

   Total

7. Saving U/S-80C

   (a) Have you got any Life Insurance Policy, other than salary saving scheme? If so, please state

        (i) Policy Number:

        (ii) Amount:

   (b) Post office C. T. D.

   (c) Equity linked Savings scheme

   (d) U. L. I. P

   (e) P. L. I.

   (f) Mutual Fund of LIC, UTI or Nationalised Banks:

   (g) P. P. F. under P. F. Act 1925

   (h) N. S. C

   (i) Mediclaim Policy

   (j) Deposit under any infrastructure Fund

   (k) Payment of tuition fee

   (l) Deposit towards any annuity plan of the life Insurance Corportion (Pension)

   (m) Any other:

   Total

8. Do you claim deduction U/S-BOL? If so, particulars of claim and amount:

9. Have you withdrawn any amount against N. S. S. or received any amount against surrender of Life insurance Policy, for which deductions have been claimed during previous years? If so, please mention the amount of such withdrawal.

   .

10. Any other information relevant to calculation of income tax and deduction/rebate/relief thereof

11. Date: