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HDFC ERGO General Insurance Company Ltd.


Payslip Emp. No: Employee Name: Shalini.G
I. A. 1 2 3 4 5 B 1 2 3 4 5 6 7 8 9


PAN No ( Mandatory ) : : Contributions / Payments Email ID / Contact No


Amount 3000 5000

Proof Required

Mediclaim u/s 80-D ( Self - 15000, Parenets - 15000, Sr. Citizen Parents - 20000 ( Max 35000 ) ) Parents Sr. Citizen : Yes / No Medical Treatment u/s 80-DD - ( Self / Spouse / Parent / Childrens / Brothers / Sisters - Max 50000 or Severe disability > 80% Rs. 1 00000 ) Medical Treatment for self totally blindu/s 80-U ( Self Only ) Education Loan Repayments u/s 80-E ( Only Interest on loan from financial institution is allowed ) ( Self, Spouse, Childrens ) Others ( Give details )

Investment Details u/s 80-C, 80CCC & 80CCF

Life Insurance Premium - LIP ( Self, Spouse, Childrens ) Public Provident Fund - PPF ( Self, Spouse, Childrens ) National Saving Certificate - NSC ( Self Only / in case of joint first name should be of employee claiming benefit ) Unit Link Insurance Premium - ULIP ( Self, Spouse, Childrens ) Equity Link Saving Scheme - ELSS ( Self ) Mutual Funds - MF ( Self ) Pension Plan - 80CCC ( Self ) School Tution Fees - Only School / College fees for 2 childrens - Only Term Fee, Tution Fee, Admission Fee Fixed Deposit for 5 years with a scheduled bank ( Self - FD Receipt should have 80-C exemption stamp ) 10000 20000

10 Housing Principal ( Stamp duty, Registration Fees, Principal Installment ) 11 Infrastructure Bonds - If Any ( Long Term Infrastructure Bonds - Notified by Central Govt.u/s 80CCF -Additional Rs. 20000/- allowed over & above max limit of Rs 1 Lac under 80C & 80CCC)

12 Others ( Give details ) C 1 2 Date of Saction of Loan :

Housing Loan Details u/s 24(2)

Self Occupied : YES / No Bank Interest Paid on Housing Loan ( Provisional Hsg Interest Certificate of Previous year need to attached as a proof )

I undertake that Interest on Housing Loan as claimed above is in respect of House Property, for which construction has been completed and the possession has already been taken by me OR is due to be taken in the current financial year. D

HRA Rebate Details u/s 10 *

Padmanaban,Flat D ,Plot No.18,Amman Appartments,CRR puram phase 2,Ganapathy Raj Street, Virugambakkam,Chennai-600092

Name & Address of the Landlord

Rent Amount p.m

PAN of Landlord
*mandatory, if rent>Rs.15000 pm

Period of Lease
From : Upto : From : Upto :

9,000 -

* HRA rebate will be given only for above period only, hence ensure you are entering correct period of rent. Mention Rent Upto period is either 31-Mar-2013 or prior to 31-Mar-2013. II. Whether any Statement provided relating to Income from Previous Employer during the year 2012-13
Employee joining after 01st April, 2012 needs to submit the details of their previous Salary Income mandatory.


I hereby confirm that I would invest/ contribute the above amounts for the purpose of rebate/deduction to be considered in calculating my income tax for the F Y 2012-2013. I further undertake that wherever eligible investments are made in the name of spouse/children/dependent parents, the same have been made out of my income and claim thereof shall not be made elsewhere to get Income Tax benefit.I will produce the tenancy/lease agreement in respect of rents paid, when called for by the company. I hereby declare that all the information given by me is true and correct. I undertake to notify you immediately of any change in the above facts. Any Income Tax liability arising out of a wrong declaration will be my responsibility, and I undertake to indemnify the Company and its officers from all consequences,monetary and otherwise, arising out of any incorrect and/or incomplete information provided in this declaration

Declaration :



Dated :

Employee's Signature

Last date for submission of Investment proofs is 10th January, 2013