Bharat Oman Refineries Limited

BORL | Payroll 1

To, Date: ____/____/___________
Vice President
Human Resource
BORL

Sub: Declarations for wage elements availed for financial year 2010-11
Sir,
I have availed the benefit of Child Education allowance during the financial year 2010-2011 for my
children whose details are as follows:
Sr. No Name Age


I have availed the benefit of Child hostel reimbursement during the financial year 2010-2011 for
my children who are staying in hostel
Sr. No. Name Age















Vehicle type Engine capacity Reg. No.









I am submitting the undertaking for points _________________________________ which are mentioned
above
Sign :_________________________________
Name : ____________________________________________________________ Employee No : ______________________
Sign:

Name:
I have availed of domiciliary treatment reimbursement for amount
of INR 15,000 in the financial year 2010-2011. I undersigned
declare that the entire amount paid under Domiciliary treatment
reimbursement has been utilized for treatment of medical ailments
and disorders for my family and myself. Bills are attached
alongwith.

Sign:

Name:
I have a vehicle which is registered on my name. This vehicle is
regularly used by me during financial year 2010-11 for official and
personal purposes. I request you to exempt from income tax the
amount eligible as per the details of the vehicle are as below:

Sign:

Name:
I have enclosed the registration
copy of the vehicle indicating the
engine capacity and my ownership
details and original bills towards
fuel & maintenance.

1
3
2
4
I have availed of books and periodicals reimbursement as a
component in my flexi basket for financial year 2010-11, the
amount paid through this component has been utilized to buy
books and periodicals for professional up-gradation the bills for
which have been attached along with this declaration.

Sign:

Name:
Bills total:
Bills total:
Sign:

Name: