Company Name Hemarus Industries Limited Emp ID 45

Employee Name SHASHIDHAR NAGANURPAN of Employee

(compulsory)AJFPN9446F

ITEMS PARTICULARS MAXIMUM LIMIT DECLARED AMOUNT

DEDUCTION U/S 10

HOUSE RENT

I am staying in a rented house and I agree to submit Leave &

Licence A'ment when required.The Rent Paid is (Rs. 5000 X 12

months) & the house is located in a METRO / NON METRO (Tick

whichever is applicable)

NON METRO 60,000.00

Max Limit Declared Amount

Sec 80D - Medical Insurance Premium (If the policy covers a

senior citizen then exemption is Rs.20,000/-) -

Sec 80DD - Handicapped Dependent -

Sec 80E - Repayment of Loan for higher education (only Interest) -

Sec 80GG - Rent Paid -

Sec 80U - Handicapped -

Sec 80CCG - Rajeev Gandhi Equity Saving Scheme

(Investment max upto Rs.50,000, would get a deduction of 50%

on the amount invested) 25,000.00

Sec 80TTA - Interest on saving a/c 10,000.00

Sec 80EE - additional deduction of Rs. 1Lac on home loan

interest (applicable only for FY2013-14) 100,000.00

Any other Deduction (Please specify)

Max Limit Declared Amount

Contribution to Pension Fund (Jeevan Suraksha) 1,00,000.00

Life Insurance Premium on life of self/spouse/child only 1,00,000.00 46,676.00

Deferred Annuity 1,00,000.00

Public Provident Fund in own name/spouse/child only 1,00,000.00

ULIP of UTI/LIC in own name or spouse and child only 1,00,000.00

Repayment of Housing Loan (Only principal) 1,00,000.00

Contribution to Pension Fund or UTI or Notified Mutual Fund 1,00,000.00

Investment in ELSS made in units of Notified Mutual Fund 1,00,000.00

Children Tuition Fee: Restricted to a max of 2 Children 1,00,000.00

Deposit in home loan account scheme of NHB/HDFC 1,00,000.00

5 yrs. Term deposit in a Sch.Bank 1,00,000.00

Others (please specify)

Others (please specify) 1,00,000.00

DEDUCTION U/S 80CCC Annuity/Pension Plan 1,00,000.00

DEDUCTION U/S 80CCD Notified Pension Scheme 1,00,000.00

Max Limit Declared Amount

Interest on Housing Loan on fully constructed accomodation

only 150,000.00

Interest if the loan is taken before 01/04/99 on fully

constructed accomodation only 30,000.00

DECLARATIONS:

1.

2.

3.

Date : 19.04.2014

Place: Rajgoli, Kolhapur SIGNATURE OF THE EMPLOYEE

HEMARUS INDUSTRIES LTD.

INCOME TAX DECLARATION FORM - F.Y. 2014-15

DEDUCTION UNDER

CHAPTER - VI A

I hereby declare that the information given above is correct and true in all respects. I am also aware that the company will be

considering the above details in utmost good faith based on the details provided by me and that I am personally liable for any

consequences arising out of errors, if any, in the above information.

(To be used to declare investment that will be made during the period from 01/04/2014 to 31/03/2015 for Income Tax purpose)

SHASHIDHAR NAGANUR

DEDUCTION U/S 80C

DEDUCTION U/S 24

Aggregate Deduction U/S 80C, 80CCC & 80CCD cannot exceed Rs. 100000/-

As per section 206AA, in case PAN is not submitted, TDS will be deducted at flat rate of 20%

Note -

I am also aware that any person making a false statement / declaration in the above form shall be liable to be fined and prosecution u/s

277 of the Income Tax Act, 1961

The proof of payment / Supportings for claim, will be provided latest by -------15 March 2015

Investment details: Amount

1) LIC JEEVAN ANAND - 636137269 11,574.00

2) MAX LIFE INSURANCE - 816441695 10,102.00

3) PNB METLIFE - 20333587 25,000.00

TOTAL 46,676.00

Provident Fund As per Deduction

House Rent -5000 X 12months 60,000.00

Form 12c

PARTICULARS OF INCOME U/S 192 (2B) FORM 12-C

FORM NO. 12C

[See rule 26B]

Form for sending particulars of income under section 192 (2B) for the year

ending 31st March, 2015

1 Name and address of the employee

2 Permanent Account Number

3 Residential Status

4 Particulars of income under any head of income other than

"salaries" (not being a loss under any such head other than the

loss under the head "Income from house property") received in

the financial year.

Rs.

(I) Income from house property _____________

(in case of loss, enclose computation thereof)

(ii) Profits and gains of business or profession _____________

(iii) Capital gains _____________

(iv) Income from other sources Rs.

(a) Dividends _____________

(b) Interest _____________

(c) Other incomes (specify) _____________

Total _____________

5 Aggregate of sub-items (I) to [(iv)] of item 4

6 Tax deducted at source [enclose certificate(s) issued under

section 203]

Place _____________

Date _____________ _______________________

Signature of the employee

______________________________

1 Inserted by the IT (Eighth Amdt.) Rules, 1987.

2 Substituted by the IT (Fourteenth Amdt.) Rules, 1998, w.e.f. 14-9-1998. Prior to its

substitution, item 4, as inserted by the IT(Eighth Amdt.) Rules, 1987, read as under:

"4. Particulars of income (not being loss) under any head other

than "Salaries" received in the financial year

(I) "Interest on securities" Rs. _____________

(ii) Income from house property Rs. _____________

(iii) Profits and gains of business or profession Rs. _____________

(iv) Capital gains Rs. _____________

(v) Income from other sources Rs. _____________

(a) Dividends Rs. _____________

(b) Interest Rs. _____________

(c) Other incomes Rs. _____________

(specify)

Total Rs. _____________

3 Substituted for "(v)" by the IT (Fourteenth Amdt.) Rules, 1998. w.e.f. 14-9-1998

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Form 12c

Form 12C 1.428

INCOME-TAX RULES, 1962

Verification

I,_________________________,do hereby declare that what is stated above is true to the best

of my knowledger and belief.

Verified today, the ____________________day of ___________________20….

Place _____________

Date _____________ _______________________

Signature of the employee

_____________________

ACTION POINTS

1 This form is to be used by an assesse-employee when he desires that his income from

sources other than "salaries" may also be taken into account by the employer for purposes of

deduction of tax of source. This form may be submitted by the assessee employee to his

employer.

2 Once the Form is submitted by the assessee employees, the employer has to take into

account the other income disclosed by the assesse and the tax deducted at source thereon

while computing the tax deductible at source from the assessee's salary.

3 From the assessment year 1999-2000, the assessee is permitted to furnish particulars in

respect of any loss under the head 'Income from house property' to his employer. The Form

has consequently been enlarged, so as to enable the assessee-employee to furnish particulars

of such loss. Employees having loss under the head 'Income from house property' will find

it to their advantage to furnish such loss (if any) to the employer, since the tax deductible at

source will get corresponsdingly reduced. This apart, such employees will also be saved from

the botheration of filing a return of income just for the purpose of obtaining tax refund.

4 The assessee-employee cannot however furnish particulars of loss (if any) under any head of

income other than 'Income from house property'.

_____________________

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