Page No : 1

T44210141216161710795140

No. of Documents Enclosed

Tax Declaration Proof FY 16-17
RefNo : 44210

Employee Code

10795140

Name

Aditya Dua

Department

IDC

PAN NO

AKZPD8513E

Location

Gurgaon

Life Insurance Premium

Declaration

Proof

Cleared

71572

Remarks

Name of Policy No. Date of

Sum
the
Commencemen Assure
Insuranc
t (dd/mm/yyyy) d
e
Company

Premiu
m Amt

Frequenc
y

Number of Number of Installment

Installmen Payable on or before 31st
t Paid on
Mar 17 (Count)
or after 1st
Apr 16
(Count)

Amount Paid on or
after 1st Apr
16(Amt)

Amount Payable on or
before 31st Mar
17(Amt)

Total Amount FY 16-17

(Paid Amt+Payable
Amt)

Relationshi
p

LIC

33234236
8

21/03/2009

600000

30850

Yearly

30850

30850

Self

LIC

12680023
0

01/02/2014

600000

40722

Yearly

40722

40722

Self

Housing Loan Principal Repayment

Declaration

Proof

Cleared

142412

Remarks

Self occupied /
Let out

Loan
owned by

Property
Location

Bank
Name

Loan Account
number

Loan Purpose

Principal
Paid

Registration Fee/Stamp Duty paid

after 1st Apr 16

% of employees Claim (in case

of Joint Loan)

Total FY
1516

Remarks

Self-occupied

Self

Gurgaon

HDFC
Ltd

609576273

Construction or
Acquisition

142412

100

142412

under
construction

Medical insurance premium paid for Parent

Declaration

Proof

Cleared

21137

Category Name of
Policy/Bill No
the
Insurance
Co /
Institution

Medical
Vidal
Insurance Health
TPA

Date
Premium Frequency Number of
(dd/mm/yyyy) / Bill Amt
Installment
Paid on or
after 1st
Apr 16
(Count)

BLR-OI-A1243-002-0034790-A 17/10/2016

21137

One time

Remarks

Number of
Installment
Payable on
or before
31st Mar
17 (Count)

Amount
Paid on
or after
1st Apr
16(Amt)

Amount Payable Total Amount FY 16on or before

17 (Paid
31st Mar
Amt+Payable Amt)
17(Amt)

Age
Group

Relationship Mode

21137

60
Years
&
Above

Parents

21137

Others

Interest on Housing Loan

Declaration

Proof

Cleared

200000

200000

Self
occupied /
Let out

Loan
Loan
owned by Purpose
self/Joint

Employee Code : 10795140

Date of
Possession
(dd/mm/yyyy)

Property
Location

Bank
/Financial
Institution
Name

Bank
/Financial
Institution
Address

Bank
/Financial
Institution
PAN

Loan
Account
number

Remarks

Annual Property
Rental Tax
Income

NAV R&M Interest % of

Loss
@
employees on HP
30%
Claim (in
case of
Joint Loan)

Remarks

Date : 26 Dec 2016

Page No : 2

Self-occupied

Loan
owned by
self

Construction
or
Acquisition

20/03/2017

Gurugram

HDFC

169, Backbay AAACH0997E

Reclamation,
Churchgate,
Mumbai 400
020

609576273

337588

100

200000

I certify that the payments listed above has been made by me out of my income chargeable to Income-tax during the financial year 2016-2017.
I undertake that I will be depositing those premium / investment / rent payments that are due for payment after the cut-off dates laid out for proof submission and obtain the receipts as per the due dates or by 31st
March 2017.
I therefore request you to consider the same for the tax computation purpose for the financial year 2016 2017. I will be held responsible for any consequences of not remitting these payments and any liabilities arise
out of this.
I hereby confirm that my house purchased / constructed is completed within 5 years from the end of the Financial Year in which the final home loan was obtained.
Signature :
Date : 26 Dec 2016

Employee Code : 10795140

Date : 26 Dec 2016

Page No : 3

FORM NO. 12BB

(See rule 26C)
Statement showing particulars of claims by an employee for deduction of tax under section 192

1.

Name and address of the employee:

Aditya Dua
C-69 Ist Floor East of Kailash
Near C Block Market
Delhi
New Delhi
Delhi
110065

2.

Permanent Account Number of the employee:

AKZPD8513E

3.

Financial year:

2016 - 2017

Details of claims and evidence thereof

SI.No

Nature of claim

Amount
(Rs.)

Evidence / particulars

(1)

(2)

(3)

(4)

House Rent Allowance:

(i) Rent paid to the landlord
(ii) Name of the landlord
1.

(iii) Address of the landlord

(iv) Permanent Account Number of the landlord
Note: Permanent Account Number shall be furnished if the
aggregate rent paid during the previous year exceeds one lakh
rupees

2.

Leave travel concessions or assistance

3.

Deduction of interest on borrowing:

(i) Interest payable/paid to the lender

337588

(ii)Name of the lender

HDFC

(iii) Address of the lender

169, Backbay Reclamation, Churchgate,

Mumbai 400 020

(iv) Permanent Account Number of the lender

(a) Financial Institutions(if available)

AAACH0997E

(b) Employer(if available)

(c) Others
4.

Deduction under Chapter VI-A

(A) Section 80C,80CCC and 80CCD
(i) Section 80C
Housing Loan Principal Repayment

142412

Life Insurance Premium

71572

(ii) Section 80CCC

(iii) Section 80CCD
(B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A.
(i) Sec 80D - Medical Insurance

21137

Verification
I, Aditya Dua ,son/daughter of Amar Dass Dua do hereby certify that the information given above is complete and correct.
Place

Gurgaon

Date

26/12/2016

Designation

Employee Code : 10795140

(Signature of the employee)

Full Name: Aditya Dua

Date : 26 Dec 2016