25
Documents required for Income tax benefits Financial Year 2011-12 This document reflects the current tax regulations and procedures governed by the Income Tax authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any amendments or change in understanding of the tax laws and prevailing at the time of such payments. Cognizant Finance Confidential Page 1 Index Interest on Higher Education Loan.......................................................................................................... 2 Loss on House Property (LOHP) .............................................................................................................. 3 i. Format of declaration for Joint Ownership .................................................................................... 4 ii. Format for Declaration of LOHP ..................................................................................................... 5 House Rent Allowance (HRA) .................................................................................................................. 6 i. Where monthly HRA <= INR 3,000 ................................................................................................. 6 ii. Where HRA> INR 3,000 & Rent <= INR 15,000 ............................................................................... 6 iii. Where HRA> INR 3,000 & Rent > INR 15,000 ................................................................................. 6 iv. Format of Rent Receipt................................................................................................................... 8 v. Format of no PAN declaration by landlord ..................................................................................... 9 Life insurance premium......................................................................................................................... 10 Repayment of Principal on Housing Loan ............................................................................................. 12 School tuition fees ................................................................................................................................. 13 Fixed Deposits ....................................................................................................................................... 14 Mutual Funds Equity Linked Savings Scheme (ELSS) .......................................................................... 15 Pension Fund (u/s 80CCC) ..................................................................................................................... 16 Infrastructure Bonds ............................................................................................................................. 17 Stamp Duty / Registration Fees for House property ............................................................................. 18 Contribution to National Savings Certificate or National Savings Scheme (NSC/NSS) ......................... 19 Unit Linked Insurance Plan (ULIP) ......................................................................................................... 20 Accrued Interest NSC.......................................................................................................................... 21 Long Term Infrastructure Bonds (u/s 80CCF) ........................................................................................ 22 Medi-claim Insurance premium (u/s 80D) ............................................................................................ 23 Maintenance of physically challenged (u/s 80DD / 80U) ...................................................................... 24 i. Certificate for Person with Disability ............................................................................................ 25

Payroll Required Documents

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Page 1: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 1

Index Interest on Higher Education Loan .......................................................................................................... 2

Loss on House Property (LOHP) .............................................................................................................. 3

i. Format of declaration for Joint Ownership .................................................................................... 4

ii. Format for Declaration of LOHP ..................................................................................................... 5

House Rent Allowance (HRA) .................................................................................................................. 6

i. Where monthly HRA <= INR 3,000 ................................................................................................. 6

ii. Where HRA> INR 3,000 & Rent <= INR 15,000 ............................................................................... 6

iii. Where HRA> INR 3,000 & Rent > INR 15,000 ................................................................................. 6

iv. Format of Rent Receipt ................................................................................................................... 8

v. Format of no PAN declaration by landlord ..................................................................................... 9

Life insurance premium ......................................................................................................................... 10

Repayment of Principal on Housing Loan ............................................................................................. 12

School tuition fees ................................................................................................................................. 13

Fixed Deposits ....................................................................................................................................... 14

Mutual Funds – Equity Linked Savings Scheme (ELSS) .......................................................................... 15

Pension Fund (u/s 80CCC) ..................................................................................................................... 16

Infrastructure Bonds ............................................................................................................................. 17

Stamp Duty / Registration Fees for House property ............................................................................. 18

Contribution to National Savings Certificate or National Savings Scheme (NSC/NSS) ......................... 19

Unit Linked Insurance Plan (ULIP) ......................................................................................................... 20

Accrued Interest – NSC .......................................................................................................................... 21

Long Term Infrastructure Bonds (u/s 80CCF) ........................................................................................ 22

Medi-claim Insurance premium (u/s 80D) ............................................................................................ 23

Maintenance of physically challenged (u/s 80DD / 80U) ...................................................................... 24

i. Certificate for Person with Disability ............................................................................................ 25

Page 2: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 2

Interest on Higher Education Loan

Provisional Certificate for current Financial year (breakup of the Principal and

Interest) for the amount due to be paid from the bank or Institution has to be

provided.

Interest portion can only be claimed.

The year in which the loan was availed has to be mentioned.

Page 3: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 3

Loss on House Property (LOHP)

Provisional Certificate for current Financial Year (breakup of the Principal and

Interest) for the amount due to be paid from the bank or Institution.

Proof of ownership (Electricity Receipt/Property tax receipt/ Sale Deed).

Form of verification needs to be attached in the prescribed format (refer below).

Notes:

o Property should be in the name of the associate to claim the tax benefit.

o Construction should be completed & occupied or let-out to claim the tax

benefit.

o Builder‘s completion certificate needs to be attached.

o Construction agreement with the builder will not be accepted.

o Both HRA & Housing Loan (as self-occupied property) cannot be claimed if

both properties are in the same city.

o Self-occupied cannot be claimed for location other than the location of actual

residing by the employee.

o Receipt for the municipal tax paid during current financial year needs to be

attached if the property is let-out and tax amount is updated in MyPay.

o All relevant documents should be uploaded separately for claiming principal

& interest benefits.

o If the self occupied property is on Joint Ownership, associate needs to submit

a declaration form from other joint owner/s in case such amount claimed is

over and above his/her share in the property.

o If the Let-out property is on Joint Ownership, associate shall claim only to the

extent of his/her share. No declaration is required for such cases.

Page 4: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 4

i. Format of declaration for Joint Ownership

Declaration for Joint Ownership

To whomsoever it may concern

This is to inform that I /we ……………………………………………………………………………………..presently residing at …………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………… wish to state that I / we am / are one of the co- owner (s) of the property situated at ………………………………………………………… ……………………………………………………………………………………………………………………………………………………… The interest paid on the borrowed capital for the said property for which I do not intend to claim in my tax return for the fiscal year _______ and I have no objection for the claim of the interest by……………………………………………………………………………………………………who is a joint owner with me of the said property either in full or 50% of the interest outgo on the borrowed capital for the said financial year _______.

Signature (s) ……………………………………………………………………………………….. ……………………………………………………………………………………….. ………………………………………………………………………………………..

Place :

Date :

Page 5: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 5

ii. Format for Declaration of LOHP

Form of Verification Please read the Instructions below before you fill up this form.

1. In case of self-occupied property, please fill up only A(c), B, C and D.

2. In case of let-out property:

i. Fill up estimated rental income for the year in A (a) ii. Repairs can be a maximum of 30% of A (a) less A (b).

3. Preconstruction interest means interest paid up to the year in which construction of the property

was completed. This interest can be claimed in five equal installments from the year in which the construction of the property was completed and four subsequent years.

4. Fill up the total loan availed in C.

5. Since you are furnishing the estimates, modify and resubmit, whenever there is a change

______________________________________________ (A) Computation of income under the head “Income from House Property”

(a) Gross Annual Rent / Value : Rs.

(b) Municipal taxes (Property tax) paid, if any : Rs.

(c) Deduction claimed for Interest paid, if any : Rs.

I. Interest accrued for the year : Rs.

II. Preconstruction interest, if any (1/5th

) : Rs.

(d) Other deductions claimed

III. Repairs : Rs.

(B) Address of the property :

(C) Amount of loan, if any and : Rs.

(D) Name and address of the lender (loan provider) :

I, ___________________ (name of the assesse), do declare that what is stated above is true to the best of my

information and belief.

Place :

Date :

Signature of the associate

Page 6: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 6

House Rent Allowance (HRA)

i. Where monthly HRA <= INR 3,000

If your monthly HRA is upto INR 3,000, there is no need to submit any documents. It

is enough if Rent values are updated and submitted in Mypay.

ii. Where HRA> INR 3,000 & Rent <= INR 15,000

If your monthly HRA is greater than INR 3,000 and your monthly rent payments are

less than or equal to INR 15,000, you would need to submit the following documents:

Original rent receipt for any one month. Note that any rent revision during the year

would need to be supported with a renewed lease agreement and rent receipt (refer

below for format).

A copy of Lease Agreement. In absence of lease agreement, rent receipt should

contain the Cheque / EFT details and additional supporting document like bank

statement extract/payment screenshot to be provided.

iii. Where HRA> INR 3,000 & Rent > INR 15,000

If your monthly HRA is greater than INR 3,000 and your monthly rent payments are

greater than INR 15,000, you would need to submit the following documents:

Original rent receipt for any one month. Note that any rent revision during the year

would need to be supported with a fresh receipt. (refer below for format)

A copy of Lease Agreement. In absence of lease agreement, rent receipt should

contain the Cheque/EFT details and additional supporting document like bank

statement extract/payment screenshot to be provided.

PAN of the Landlord (or) the Declaration from Landlord if he/she does not have a

PAN. (refer below for format)

Page 7: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 7

Notes:

o The format for the rent receipt is given below. Please ensure that your receipt

includes all the Information mentioned in the format.

o Please note that only the amount paid towards rent is eligible for exemption.

Other amounts paid, such as maintenance charges, electricity bill, etc., food in

case of paying guest accommodation are not eligible for exemption.

o Lease period (start date and end date) should be clearly mentioned in the

lease agreement.

o In case of lease agreement which does not cover the entire period of current

financial year a copy of the new/renewed rental agreement has to be

submitted on or before 24th of the month following the month in which the

new accommodation or renewal of the existing accommodation is done.

o PAN of Land lord will be validated for its correctness before approval.

o The Rental Agreement should be in a Stamp Paper. Renewal of lease

agreement also to be in Stamp paper only.

o In case of Hostel accommodation, rent receipt in the hostel’s letter head or

pre-printed receipt book can be submitted towards rent payment proof.

o In case if there is no lease agreement, PAN of the Hostel Owner is to be

provided or the Non PAN declaration from the Hostel Owner, is to be

provided in the prescribed format given below irrespective of the rent

amount.

o In case the lease is taken on joint names and if the total amount of rent paid

is more than Rs. 15,000 per month, PAN number or declaration for not having

PAN (as the case may be) from Landlord is required irrespective of the fact

that the share of the associate is lesser than Rs.15,000 per month.

Page 8: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 8

iv. Format of Rent Receipt

Rent Receipt

Received a sum of Rs.………………… /- (Rupees ……………………………………………………………………

……………………………………………………………………………….) vide cheque no. …………………..drawn

On …………………………………………. Bank dated ……………………………….. from Mr./ Ms. ……………

…………………………………………………………………………………………. residing at …………………………….

………………………………………………………………………………………………………………………………………….

Towards rent for the month of …………………………. 20…..

Place :

Date :

Signature of the landlord

(To be signed on the revenue stamp)

Name of the landlord :

PAN of the landlord :

Address :

Page 9: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 9

v. Format of no PAN declaration by landlord

Declaration to be provided by the Landlord for Non availability of Permanent Account Number

(PAN)

To whomsoever it may concern

1. Name :

2. Address of the leased property :

3. Are you assessed to tax :

4. Reasons for not having PAN :

5. Details of document being

produced in support of address : (Refer instructions below)

Verification

I, ______________________________ do hereby, declare that what is stated above is true

to the best of my knowledge and belief.

Verified today, the __________________ day of __________________

Date :

Place :

Signature of the Landlord

Instructions:

Documents which can be produced in support of the address are:

(a) Copy of the electricity bill for the leased property (or)

(b) Copy of property tax / water tax payment challan for the leased property

Page 10: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 10

Life insurance premium

Receipt for Insurance Premium paid during the current financial year.

For online payment - Statement from Insurance Company showing the current year

payments can be provided.

Notes:

o Policy can be in the name of the associate, spouse or children only.

o In case of Single premium policy the amount is restricted to 20% of the actual

capital sum assured.

Page 11: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 11

Public Provident Fund (PPF)

Front page of the pass book issued by the bank / post office.

Copy of the relevant page(s) containing details of deposit made for the current

financial year.

Notes:

o Account should be in the name of the associates or his/her spouse or minor

children

o Only current year contribution excluding interest accrued, if any can be

claimed.

Page 12: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 12

Repayment of Principal on Housing Loan

Bank Certificate mentioning the principal repayment to be attached and iIt should

clearly state the purpose as Housing Loan.

Breakup of Interest and Principal should be clearly mentioned in the certificate.

Documents evidencing the ownership of the property. Sale deed, if property is

acquired in current year.

For existing property Electricity Bills / Property taxes payment receipts of the latest

available month for the current financial year

Notes:

o Wherever a HRA benefit is also claimed, the address as disclosed in the

certificate is corroborated with the address furnished in the declaration.

o No Objection Certificate (NOC) /Declaration from spouse or co owner

mentioning that he/ she not claiming the benefit or to the extent of claiming

for the relevant financial year.

Page 13: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 13

School tuition fees

Receipt issued by the Schools for the payment made during the Current financial year

Notes:

o Only allowed for two children.

o Crèche fees not allowed.

o Only Term fees are allowed. Capitation fee, Donation or any other payments

are not allowed.

Page 14: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 14

Fixed Deposits

Copy of the Deposit receipts for the investment done during the current financial

year

Notes:

o Period of deposit should be for a minimum of five (5) years with a Scheduled

Bank only. Receipt should contain the words “Issued under tax scheme”.

Page 15: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 15

Mutual Funds – Equity Linked Savings Scheme (ELSS)

Statement from Asset Management Company for the current financial year

Notes:

o Receipt should be in the name of the associate.

Page 16: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 16

Pension Fund (u/s 80CCC)

Certificate evidencing payments to pension funds and its eligibility for a deduction

under this section during the current financial year.

Notes:

o Receipt should be in the name of the associate.

Page 17: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 17

Infrastructure Bonds

Copy of the Bond / Certificate.

Acknowledgement receipt along with account statement evidencing the debit in the

account.

Notes:

o Bond should be in the name of the associate.

Page 18: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 18

Stamp Duty / Registration Fees for House property

Receipt should have been issued by the Sub registrar office.

Property Completion certificate of the property needs to be attached

Notes:

o Property should be completed within the same financial year of purchase or

registration.

o Amount has to be updated as part of Principal Repayment u/s 80C

Page 19: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 19

Contribution to National Savings Certificate or National Savings Scheme (NSC/NSS)

Certificate issued under the NSC/NSS scheme in the current financial year has to be

attached

Notes:

o Certificate should be in the name of associate only.

Page 20: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 20

Unit Linked Insurance Plan (ULIP)

Copy of the Investment certificate / receipt for the current financial year has to be

attached.

Notes:

o Certificate should be in the name of the associate, his/her spouse or children.

Page 21: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 21

Accrued Interest – NSC

Copy of old NSC Certificate (s) should be attached.

Interest calculation sheet should also be attached.

Notes:

o Associate to ensure Interest shown here should also be included as other

income while filing his/her Income tax return.

Page 22: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 22

Long Term Infrastructure Bonds (u/s 80CCF)

Copy of the Bond / Certificate.

Acknowledgement receipt along with account statement evidencing the debit in the

account.

If this is invested through Demat account, the Demat account relevant page/s

showing the date of investment and the name of the investor with the Fund name

and amount clearly mentioned.

Notes:

o The investment should be in the name of the associate. If this is joint

investment then the first name should be of the associate

o Please enter the certificate number in the Reference Number field. If you

have invested through Demat account, enter the Transaction number.

o If this is invested through Demat account, the Demat account relevant page/s

showing the date of investment and the name of the investor and the Fund

name and amount should be clearly mentioned.

Page 23: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 23

Medi-claim Insurance premium (u/s 80D)

Medical insurance premium receipt for the current financial year.

Notes:

o If the policy is in the name of the family member, a declaration from the

family members, stating that the benefit is not being claimed by them and

that the payment is made out of the employee's taxable income, be obtained.

o Family includes spouse, parents or dependent children of the associate.

Page 24: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 24

Maintenance of physically challenged (u/s 80DD / 80U)

Certificate with details of percentage of disability in Form 10IA (Format of the same is

attached) signed by a Doctor of a Government Hospital.

Notes:

o Self-disability is claimed under sec 80U and dependents under 80DD.

o Handicapped dependent for whom the amount of Medical expenditure is

incurred are spouse, children, parents, brothers and sisters of the associate.

Page 25: Payroll Required Documents

Documents required for Income tax benefits – Financial Year 2011-12

This document reflects the current tax regulations and procedures governed by the Income Tax

authorities. The taxability of perquisites, allowances etc., may be subject to change depending on any

amendments or change in understanding of the tax laws and prevailing at the time of such payments.

Cognizant Finance Confidential Page 25

i. Certificate for Person with Disability

FORM NO. 10-IA

[See sub-rule (2) of rule 11A] Certificate of the medical authority for certifying ‘person with disability’, ‘severe

disability’, ‘autism’, ‘cerebral palsy’ and ‘multiple disability’ for purposes of section 80DD and section 80U

Certificate No. Date: This is to certify that Shri/Smt./Ms._______________________________ son/daughter of Shri_________________________________, age______ years___________male/female* residing at____________________________________, Registration No.__________is a person with disability/severe disability* suffering from autism/cerebral palsy/multiple disability*. 2. This condition is progressive/non-progressive/likely to improve/not likely to improve*. 3. Reassessment is recommended/not recommended after period of__________months/years*.

Sd/- (Neurologist/Pediatric Neurologist/Civil Surgeon/

Chief Medical Officer*) Name:___________________ Address of Institution/Government hospital: ____________________________________ ____________________________________ Qualification/designation of specialist :____________________ SEAL Signature/Thumb impression* of the patient Note: *Strike out whichever is not applicable.