DECLARATION FORM FOR AVAILING REBATE FROM SALARY FOR THE YEAR 2016-17

Pioneer Gas Power Ltd EMP. CODE

Accounts Deparment,
INCOME TAX REBATE FOR PAYMENT / INVESTMENT MADE DIRECTLY
(Need not be filled in if paid through salary)
I request you to grant me rebate on the amounts invested as mentioned below while deducting
income tax from my salary from 1st April, 2016 to 31st March, 2017. The necessary receipts / pass
books are will be produced on or before 10th Feb, 2016.
Name : _____________________________________
Deptt. : _____________________________________
Income Tax P.A. No. : _____________________________________
Amount
Rs.
A. Mediclaim Insurance Premium U/S 80D ______________
B. House Rent Paid – Rebate U/S 10(13A)
April ___________May___________June___________July___________
Aug____________Sept___________Oct____________Nov___________
Dec____________Jan_____________Feb___________Mar___________ ______________
C. Conveyance Allowance – Exempt U/S 10(14) read with Rule 2BB-Maximum
Rs.1600/- P.M. i.e. Rs.19,200/- for full year.
I hereby state that the expenses incurred from my residence to place of
my duty are Rs.1600/- p.m. ______________
D. Investment U/S 80C -
1. Life Insurance Premium Policy No. / A/c. No. Due date of payment Amount (Rs.) (yearly)
i) _____________________________________ _______________ ______________
ii) _____________________________________ _______________ ______________
2. Unit Linked Insurance Plan _______________ ______________
3. Public Provident Fund _______________ ______________
4. LIC & other Pension Schemes U/S 80CCC _______________ ______________
5. Bank Fixed Deposit for 5 years & above _______________ ______________
6. Amount invested in Equity Linked Plan etc. _______________ ______________
7. Repayment of Principal Amount of Housing Loan _______________ ______________
8. Interest on Housing Loan U/S 24(i) _______________ ______________
9. Children’s Education Expenses
(for maximum 2 children) _______________ ______________
10. Exemption for Senior Citizen _______________ ______________
11. National Savings Certificates VIII Issue _______________ ______________
12. Other Declaration _______________ ______________
_______________________________________ _______________ ______________
_______________________________________ _______________ ______________
________________________________________ _______________ _____________

I hereby declare that Information as stated above is true and correct . I also authorize the
company to recover tax (TDS) from my salary based on the PROOFS Submitted by me. I am
personally liable to Income Tax proceedings for any misstatements in the declaration or proofs
submitted herewith if they are inconsistent with the requirement of Income Tax Act, 1961.

Date : ______________
Place: (Signature)