Affiliated Computer Services of India Pvt Ltd

Emp No. Emp Name PB0022 MANU PANICKER

Department ALLSCRIPTS-BARODA DOJ PAN 1-Aug-11 AQFPP2541L

Proof submission for the financial year 2011-12

Sl. No. Nature of Exemption Documents to be produced Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes Refer Notes 3 78,000.00 No of Documents attached / enclosed Amount

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Date: Place:

Leave Travel Assistance - (LTA) Medical Reimbursement Telephone Expenses Reimbursement Books & Periodicals Reimbursement Vehicle Log Declaration Vehicle Log Book VER - Fuel Expenses Reimbursement VER - Repairs & Maintenances Reimbursement VER - Vehicle Insurance Reimbursement VER - Vehicle Parking Reimbursement VER - Chauffeurs Salary Reimbursement Declaration-ACS Cab Facility Computer Maintenance & Internet Connectivity Reimbursement Uniform Allowance Helper Allowance Rent Receipt Housing Loan Interest Contribution to Pension Fund - 80CCC Life Insurance Premium - 80C Public Provident Fund - 80C Deposit in Post Office Saving Scheme - 80C Deposit in NSC - 80C ULIP - 80C Principle Loan Repayment - 80C Mutual Funds - 80C NHB Scheme - 80C Fixed Deposit in Banks >5 Yrs - 80C Children Education - 80C Long term infrastructure bonds - 80CCF Mediclaim Insurance Premium - Sec 80D Interest on Education Loan Repayment - Sec 80E Medical Expenses of Handicapped Dependent - Sec 80DD Physically Handicapped Employee - Sec 80U Other Income

39,932.00

Refer Note No. 6 below

Refer Notes No. 7 below Refer Notes No. 8 below Refer Notes No. 9 below Refer Notes No. 10 below Refer Notes No. 11 below Refer Notes No.12 below

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Medical Reimbursement - Bills Submission for the year 2011-12
Emp No: Emp Name: DOJ: Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Total I here by declare that above information is correct and I certify that the above expenditure is incurred towards medical expenses for self and my dependent family Bill No Date Patient Name Relationship Age Amount

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Leave Travel Assistance - Proof Submission for the year 2011-12
Emp No: Emp Name: DOJ: Places Visited Date From To Mode of Travel

Details of Dependents traveled & cost incurred Name Age Relationship Amount

Total Previous Years Exemption details Year 2010 2011 Company Amount (Optional)

I here by certify that the above mentioned information is correct and I further confirm that I shall be fully responsible for any Income Tax Liability that may arise if this declaration is defective in any manner.

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Telephone Expense Reimbursement - Bills Submission for the year 2011-12
Emp No: Emp Name: DOJ: Telephone numbers in respect of which the reimbursement is claimed: Sl. No. 1 2 3 4 Telephone / Mobile Number

Sl. No. 1 2 3 4 5 6 7 8 9 10

Bill No

Date

Name appearing on the bills

Phone No

Amount

Total

I here by certify that the above information is correct and I have incurred the above expenditure for office use.

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Books & Periodicals Reimbursement - Bills submission for the year 2011-12
Emp No: Emp Name: DOJ: Sl. No. 1 2 3 4 5 6 7 8 9 10 Total I hereby certify that the above expenses are incurred by me for purchasing books only Bill No Date Details of Books Purchased Amount

Date:

Signature of the Employee

Self Declaration

List

To, The Payroll Department Affiliated Computer Services of India Pvt Ltd Bangalore For the Financial Year 2011-12

(EMP No. ) Son / Daughter of hereby declare that, I am maintaining a log book for the above said period with complete details of Journey undertaken for official purpose which include date of journey, destination, distance and the amount of expenditure incurred thereon. The same will be produced when requested. I further declare that the expenditure was incurred wholly and exclusively for the performance of official duties and will be personally responsible for any Income Tax related issues that may arise on this account while employed with ACS or thereafter.

Signature Name: Emp ID: WIN ID: Date:

Affiliated Computer Services of India Pvt Ltd

Vehicle LOG details for the month of Emp No: Emp Name: Car Make: Model: Car Registration No. Date From Destination To Odometer (KM) Reading Opening Closing Distance Rate per KM Amount Spent (in Rs.) Remarks

Travelled (Rate is Fixed at (KM) Rs.8/- per KM) Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M Rs.8.00/- Per K M

Total Amount DECLARATION

I certify that the above travel are for the purpose of Company's business only.
Date: Location:

Signature of the Employee Note: Rate is fixed at Rs. 8/- per KM

Affiliated Computer Services of India Pvt Ltd

Fuel Expense Reimbursement - Bills submission for the year 2011-12 Emp No: Emp Name: VER * Start Date: Car Registration No. Sl. No. 1 2 3 4 5 6 7 8 9 10 Total Amount I certify that the above expenses are incurred for the purpose of Company's business only. Bill No Date Amount Sl. No. 11 12 13 14 15 16 17 18 19 20 Bill No Date Amount

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Repairs & Maintenance Reimbursement - Bills submission for the year 2011-12 Emp No: Emp Name: VER * Start Date: Car Registration No. Sl. No. 1 2 3 4 5 6 7 8 9 10 Total Amount I certify that the above expenses are incurred for the purpose of Company's business only. Bill No Date Amount Sl. No. 11 12 13 14 15 16 17 18 19 20 Bill No Date Amount

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Vehicle Insurance Reimbursement - Bills submission for the year 2011-12 Emp No: Emp Name: VER * Start Date: Car Registration No. Sl. No. 1 2 3 4 Total Amount I certify that the above expenses are incurred for the purpose of Company's business only. Policy Number Date of Premim paid Amount

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Vehicle Parking Reimbursement - Bills submission for the year 2011-12 Emp No: Emp Name: VER * Start Date: Car Registration No. Sl. No. 1 2 3 4 5 6 7 8 9 10 Total Amount I certify that the above expenses are incurred for the purpose of Company's business only. Bill No Date Amount Sl. No. 11 12 13 14 15 16 17 18 19 20 Bill No Date Amount

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Chauffeur's Salary Reimbursement - Proof submission for the year 2011-12

To, The Payroll Department Affiliated Computer Services of India Pvt Ltd Bangalore Sub: Reimbursement of Chauffeur Salary for the Month of . Dear Sir, I request you to reimburse the salary paid to the Chauffeur. The relevant receipt from the Chauffeur is attached herewith.

Date: . Employee ID: .. Employee Name: Employee Signature: .

Salary Receipt
Received Rs. ./- towards salary for the month of ..

List

Affiliated Computer Services of India Pvt Ltd

Declaration form for claiming Income Tax rebate on Vehicle Expense Reimbursement for the year (2011 - 2012)
Emp No : Emp Name : DOJ :

Month
Aug 2011

ACS Transport facility availed

Signature of Employee

Signature of LOB Head Remarks

YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO
DECLARATION
I hereby declare that the above information is correct

Sep 2011

Oct 2011

Nov 2011

Dec 2011

Jan 2012

Feb 2012

Mar 2012

Location Date Signature

Please note,
1 2 This template will applicable only to employees who are availing ACS Transport facilities. If employee has availed the ACS transport facility for any of the above said months, then the Tax Exemption towards VER for that period will not be provided

Affiliated Computer Services of India Pvt Ltd

Computer Maintenance & Internet Connectivity Reimbursement - Proof submission for the year 2011-12 Emp No: Emp Name: DOJ: Sl. No. 1 2 3 4 5 6 7 8 9 10 Total I hereby certify that the above expenses are incurred by me are towards official / business purposes only Bill No Date Details of items Purchased Amount

Date:

Signature of the Employee

Affiliated Computer Services of India Pvt Ltd

Uniform Allowance Reimbursement - Proof submission for the year 2011-12

To, The Payroll Department Affiliated Computer Services of India Pvt Ltd Bangalore Sub: Reimbursement of Uniform Allowance for the Month of .

Dear Sir,

I hereby certify that I have incurred an expense of Rs.___________ towards the Uniform expenses for the month of _____________ Please reimburse the same.

I further declare that the expenditure was incurred wholly and exclusively for the performance of official duties and will be per responsible for any Income Tax related issues that may arise on this account while employed with ACS or thereafter.

Date: . Employee ID: .. Employee Name: Employee Signature: .

Affiliated Computer Services of India Pvt Ltd

Helper Allowance Declaration - Proof submission for the year 2011-12

To, The Payroll Department Affiliated Computer Services of India Pvt Ltd Bangalore Sub: Helper Allowance for the Month of .

Dear Sir,

I hereby certify that the entire amount of Helper Allowance received by me of Rs.___________ has been fully spent in discharge o official obligations.

Date: .

Employee ID: .. Employee Name: Employee Signature: .

Salary Receipt
Received Rs. ./- towards salary for the month of ..

Date: Rent Receipt

Received Rs. _______________ from ______________________________________ by Cash / Cheque / DD no__________________ dated _______________ towards rent for for the month of ________________________ Address of the House:

Signature of the House Owner Name: Address:

Rent Receipt

Signature of the House Owner