PGBRK IPSF|862|20054442|00862000000000000308||W||

All the proofs have to be uploaded using the scan image option using the link "Upload IPSF Proof Images/Images Multiple". No hard
copy proofs will be accepted. Please ensure to consolidate all the images of your investment proofs and self-declarations and upload
accordingly.
Rockwell Automation India Pvt. Ltd IPSF ID : 00862000000000000308
Investment Proofs Submission Form for the Year 2023-2024
Employee ID* 20054442 Gender* M Date of Joining 03/06/2013
Name* Kunal Kunal No.of Children Going to School 1
PAN* APYPK1441G No.of Children Going to Hostel 0
Regime Type Old Regime
Section A - Rent Paid for claiming HRA exemption (Only Rent Receipts will be considered)
From Date To Date Address Rent Paid Per Rent Paid Per Property ID
Month Annual
01/04/2023 31/03/2024 Flat-740A Gali No- 7 Pandav 35000.00 420000.00 1
Nagar New Delhi 110092,NEW
DELHI,DELHI
As Per Last Declaration Section B - Chapter VI A - Deductions from Total Income Value of Proof Attached
26605 Medical Insurance - Self / Spouse / Children (<60 yrs) - With Insurance 26605.00
0 Medical Insurance - Self / Spouse / Children (>=60 yrs) - With Insurance 0.00
0 Medical Insurance - Self / Spouse / Children (>=60 yrs) - Without Insurance 0.00
0 Medical Insurance for Parents (<60yrs) - With Insurance 0.00
62021 Medical Insurance for Parents (>=60yrs) - With Insurance 60752.00
0 Medical Insurance for Parents (>=60yrs) - Without Insurance 0.00
0 Medical Treatment/Handicapped Dependent (U/s 80DD) < 80% 0.00
0 Medical Treatment/Handicapped Dependent (U/s 80DD) > 80% 0.00
0 Interest on Educational Loan (U/s 80E) 0.00
0 Permanent Physical Disability (80U) < 80% 0.00
0 Permanent Physical Disability Severe Disabilitty (80U) > 80% 0.00
40000 Medical Treatment of Specified Diseases (80DDB) 0.00
0 Medical Treatment of senior citizen (80DDB) 100000.00
0 Medical Treatment of very senior citizen (80DDB) 0.00
0 Additional Housing Loan Interest Benefit (U/s 80EE) 0.00
50000 Additional NPS Employee Contribution (U/s 80CCD1B) 0.00
0 Atal Pension Yojana (U/s 80CCD1B) 0.00
150000 Electric Vehicle Loan Interest Benefit (U/s 80EEB) 175000.00
0 Additional Housing Loan Interest Benefit (U/s 80EEA) 0.00
0 Deduction for Interest on Deposits in Savings Account (U/s 80TTA) 0.00
0 Deduction for Interest on Deposits in case of Senior Citizens (U/s 80TTB) 0.00
Section C - Chapter VIA - Section 80C
0 Contribution to Pension Fund ( 80CCC ) 0.00
0 Public Provident Fund (PPF) 0.00
0 National Savings Certificate (NSC) 0.00
0 Infrastructure Bonds 0.00
120081 Children Education Tuition fees 107975.00
0 Equity Linked Savings Scheme (ELSS) 0.00
0 Mutual Funds 0.00
0 Unit Linked Insurance Plan 0.00
0 5 Year Deposit under Senior Citizen Saving Scheme 0.00
0 Cumulative Term Deposits 0.00
0 5 Year Time Deposit in Post Office 0.00
0 NPS Employee Contribution (U/s 80CCD) 0.00
0 Atal Pension Yojana (U/s 80CCD) 0.00
0 Sukanya Samriddhi Scheme 0.00
83068 Housing Loan - Principal Amount paid, Registration Fees, Stamp duty 28006.00
0 Fixed Deposit Scheme (Block Period of 5 yrs) 0.00
0 NSC Interest (Will also be considered as Other Income) 0.00
Section D(b) -Loss from House Property - SELF OCCUPIED
-200000 Loss from House Property - SELF OCCUPIED -200000.00
Section G -Other Income
0 Bank Interest (excluding interest on savings account) 0.00
0 Interest Income to Senior Citizen(Considered as deduction u/s 80TTB upto Rs.50000) 0.00

Note: This document is computer generated. Hence, does not require manual signature for authentication
EPSF Confirmed on :15-01-2024 11:24:00
 0 Interest on Deposits in Savings Account (Considered as deduction u/s 80TTA upto Rs.10000) 0.00
0 Others 0.00
0 Interest on PF Account 0.00
0 NSC Interest (Other Income) 0.00

Payroll Deduction
Particulars Amount
Provident Fund 89355.00
Payroll Deduction - Total 89355.00

Dependent Details:
Dependent Name Relationship Age
Kunal Kunal Self 43
Shalini Sinha Spouse 42
Rita Prasad Mother 69
Shaurya Samarth Son 10

Note:-
I, hereby, declare that I have read and understood the IPSF guidelines provided by the Firm and that all information/documents provided by me are true and correct to the best of
my knowledge. If any of the information is found to be false or misleading, the Firm holds the right to take a disciplinary action against me.
I also understand that Firm reserves the right to scrutinize the information and investment proof submitted by me and disallow tax benefit without providing any explanation. I
understand that if disallowed by the Firm. I can claim that benefit while filing my income tax return. I also recognize that if needed the Firm could ask for further documents or
original documents to verify and validate the investments tax saving proofs submitted by me.
I, hereby, declare that the investment proofs submitted by me for the current financial year have not been claimed by my relations in my current organization or any other
organization for the same financial year.
I further undertake to indemnify the company for any loss/liability that may arise, in the event of any incorrect information/documents
* Indicates mandatory fields as per our database. Please verify the same and if blank, please fill and submit the form.

HRA Land Lord Details

Property Id Landlord Name Landlord Pan Landlord Address Annual Rent
1 SHALINI SINHA CDNPS5970F Flat-740B Gali No- 7 Pandav 420000
Nagar New Delhi 110092

Note: This document is computer generated. Hence, does not require manual signature for authentication
EPSF Confirmed on :15-01-2024 11:24:00
 HRA FUTURE RENT DECLARATION

Rockwell Automation India Pvt. Ltd

EMP ID 20054442
EMP NAME Kunal Kunal
RENT AMOUNT PER MONTH 35000
FOR THE PERIOD 01-01-2024 TO 31-03-2024
LANDLOARD NAME SHALINI SINHA
LANDLOARD PAN CDNPS5970F

The proofs/original rent receipts would be submitted on request along with the copy of the Self declaration.

Employee Declaration

I hereby declare that the information provided above is true and correct and will be solely responsible for any situation arising out of non-payment of the above rent.

Note: This document is computer generated. Hence, does not require manual signature for authentication
EPSF Confirmed on :15-01-2024 11:24:00
 Self declaration given for possession of Housing property(in the absence of Possession certificate) - Self Occupied(1)

(Applicable if housing loan interest /principal deduction benefit is claimed u/s 24)

This is to declare that I Kunal Kunal ,have gained the ownership/possession of my house property located at the following address, on 24/10/2019 (DD/MM/YYYY).

Address :

Flat-20076 Tower-3 Mahagun Mywoods Gaur City-2 Noida

GAUTAM BUDH NAGAR

Loan Lender/Bank Name : ICICI Bank

Loan Sanction Date : 24/10/2019

Note: Section 24(b) of the Act allows deduction from income from house property on interest on borrowed capital as under:-
(i) The deduction is allowed only in case of house property which is owned and in the occupation of the employee for his own residence. However, if it is not actually occupied
by the employee in view ofhis place of the employment being at other place, his residence in that other place should not be in a building belonging to him.
(ii) The house so acquired or constructed should be completed within 5 years from the end of the FY in which the capital was borrowed. Hence it is necessary for the DDO to
have the completion certificate of the house property against which deduction is claimed either from the builder or through self-declaration from the employee.

Note: This document is computer generated. Hence, does not require manual signature for authentication
EPSF Confirmed on :15-01-2024 11:24:00
 FORM NO. 12BB
(See rule 26C)

Statement showing particulars of claims by an employee for deduction of tax under section 192
1. Name and address of the employee : Kunal Kunal
2. Permanent Account Number of the employee : APYPK1441G
3. Financial year : 2023-2024
Details of claims and evidence thereof
Sl. No. Nature of claim Amount(Rs.) Evidence/Particulars
(1) (2) (3) (4)
House Rent Allowance:

Property No :1
(i) Rent paid to the landlord Rs.420000
(ii) Name of the landlord SHALINI SINHA
1. Rs.420000.0 House Rent Receipts
(iii) Address of the landlord Flat-740B Gali No- 7 Pandav Nagar New
Delhi 110092
(iv) Permanent Account Number of the CDNPS5970F
landlord

2. Leave Travel Concessions or Assistance Rs.0.0 Travel Receipts/Tickets

Deduction of Interest on Borrowing:

Self Occupied Property 1

(i) Interest Payable/Paid to the Lender Rs.-256176
(ii) Name of the Lender ICICI Bank
(iii) Address of the Lender ICICI Bank Tower, Near Chakli Circle, Old
Padra Road, Vadodara, Gujarat - 390 007. Provisional Certificate from
3. Rs.-200000.0 Bank/Financial Institution/Lender
(iv) Permanent Account Number of the AAACI1195H
Lender
(a) Financial Institutions
(b) Employer
(c) Others

Self Occupied Property Total Interest Rs.-200000

Deduction under Chapter VI-A

(A) Section 80C,80CCC and 80CCD

(i) Section 80C

(a) Provident Fund : Rs.89355

(b) Housing Loan - Principal Amount paid, Registration : Rs.28006

Fees, Stamp duty
(c) Children Education Tuition fees : Rs.107975
Photocopy of the investment
4. Rs. 587693.0
(ii) Section 80CCC : proofs

(iii) Section 80CCD

(B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A.

(a) Medical Treatment of Specified Diseases (80DDB) : Rs.100000

(b) Electric Vehicle Loan Interest Benefit (U/s 80EEB) : Rs.175000

(c) Medical Insurance (SEC80D) : Rs.87357

Verification
I, Kunal Kunal, Son/Daughter of A.N. Prasad. do hereby certify that the information given above is complete and correct.
Place : Noida

Date: 15-01-2024

(Signature of the Employee)

Designation : Team Lead Business Operations Full Name: Kunal Kunal

Note: The information/details above, as required for deduction of tax u/s 192 of the Income Tax Act, has been entered by the employee through an authorized login on
the portal.

Note: This document is computer generated. Hence, does not require manual signature for authentication
EPSF Confirmed on :15-01-2024 11:24:00