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Medical Declaration Form (ANNX III)

The document is a declaration of medical expenses incurred from 2010-2011 by an employee and their family as defined by tax law. It lists the dates, bill numbers, relationships, and amounts of medical bills submitted as evidence of expenditures on medical treatment. The total expenses are provided in rupee amounts both numerically and in words. The employee has signed to declare these expenses towards any tax deductions.

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venkatesh425
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© Attribution Non-Commercial (BY-NC)
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31 views

Medical Declaration Form (ANNX III)

The document is a declaration of medical expenses incurred from 2010-2011 by an employee and their family as defined by tax law. It lists the dates, bill numbers, relationships, and amounts of medical bills submitted as evidence of expenditures on medical treatment. The total expenses are provided in rupee amounts both numerically and in words. The employee has signed to declare these expenses towards any tax deductions.

Uploaded by

venkatesh425
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Medical Expenses (FY 2010-11)

I hereby declare that I have incurred the following expenses on self and family
( as defined in the Income Tax Act) for the financial year 2010-11 towards the
medical treatment of myself and my family (as defined under the Income Tax
Act**). I am also enclosing the medical bills evidencing the expenditure incurred
by me in this regard. The details of the medical bills submitted are as under:

Date Bill No Relationship Amount

Total (Rs.)
Total (Rs in
words)

** Family means
(i) spouse and children of the employee and
(ii) parents, brothers and sisters of the individual or any of them
wholly or mainly dependent
on the individual.

Employee Signature:

Employee Name ( as per


Company records):

Employee Code (as per Company


records):
Employees location:

Dated:

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