Last Date of Submission of Actual Proofs : 20th January 2011

Kelly Services India Pvt. Ltd.

EMPLOYEE PROOF SUBMISSION FORM FOR THE FINANCIAL YEAR 2010 - 2011
Employee Name * Employee Code *
Date of Joining * City Permanent A/c Number (PAN) * :
Email id * Tel No Father's Name *
Date of Birth * Gender * : Mobile No

Permanent
Address *

Value of Proof Amount Authorised

Sr. No. Description Maximum Investment Limit Enclosed (To be (To be filled up by
filled up employee) Finance Dept. only)

A DEDUCTIONS UNDER CHAPTER VI - A

1 80D - Medical Insurance Premium (Copy of Premium Receipt)
15,000 for self and Family + 15000 if parent
covered+5000 if Parent Sr Citizen
Parents covered Whether Parents Sr Citizen (Yes /
(Yes / No) = > No) = >
2 80DD - Medical Treatment of Dependent suffering from Permanent Disability (Certificate 50,000 (in case of severe disability -
From Govt. Hospital & Self declaration) 75,000)
3 80DDB - Expenditure on Medical Treatment for specified disease (Medical Cirtificate from 40,000 or 60,000 for Senior Citizen
4 Recognised Hospital)
80E - Repayment of Higher Educational Loan (Proof of Repayment) No Limit. ( Interest component only)
5 80U - Permanent Physical Disability (Personal) (Certificate From Govt. Hospital & Self
declaration) 50,000 ( incase of severe disability 100,000)
Total under Chapter VI - A deductions
B INVESTMENT UNDER SECTION 80CCE + 80CCF ( Maximum limit is 1,20,000/- )

6 Life Insurance Premium paid by an employee, on his life & dependents (Min 2 year Plan)
7 Education expenses - Photocopy Bills (Inclued only Tution Fee Max for Two Childrens)
8 Deferred Annuity
9 PPF - Photocopy of the Passbook & Copy of the deposit slip (Max 70000/-)
10 Deposit in Post Office Saving Scheme (Min 5 years Plan)
11 National Saving Scheme (NSS) & National Saving Certificate Deposit (NSC)
12 Unit Linked Insurance Plan (ULIP) of UTI/ LIC Mutual Fund (Min 5 Years Plan) Limit upto Rs 1,00,000 in any other
13 Accrued Interest on NSC (Copy of Old Certificates to be Enclosed) investment mentioned from serial no 6 to 19
+ additional 20000 for serial no 20.
14 Mutual Funds (Min 3 Years Plan)
15 Infrastructure Bonds (Min 3 Years Plan)
16 Housing Loan Principal Repayment
17 NHB Scheme
18 Fixed Deposits with scheduled Bank for 5 yrs or more (xerox copy required)
19 80CCC - Contribution to certain pension funds (Anuuity Plan of LIC)
20 80CCF Long term infrastructure bond
21 Others (Specify)
Total Investment u/s 80CCE+80CCF ( Maximum 1,20,000/- )
C Interest on Housing Loan (Attach Form 12 C along with Interest Certificate)
Restricted up to Rs.1,50,000 if the loan taken after 1-4-99, Rs
22 a) Self Occupied 30,000 if it is prior to 1-4-1999
23 b) Let Out - No Restriction- Calculation need to be provided No Limit
D - 24 Income Other than Salary (Attach Form 12 C detailing other income)

E - 25 Medical Bills (Original) (Against Reimbursement paid on monthly basis) **Non medical
Expenses such as Cosmetics, Health Drinks, Multi Vitamins (without doctor's
prescription), Baby Foods, Health club/ fitness expenses & other restricted drugs are Maximum 15000/- PA
not permissible for medical reimbursement)

F
Previous Employment Salary (Salary earned from 01/04/2010 till date of Joining)
Attach Photocopy of Form 16 from Previous employer or Form 12B & Attested Photocopy of the Income Certificate
from previous employer (Mandatory for all new joinee joined after 1st April 2010 - No investment proofs will be considered in
the absence of Form12B and proof of income)
26 Previous Employer Income ( As per Form 16 / Form 12 B) -
27 Previous Employer PF ( As per Form 16 / Form 12 B) -
28 Previous Employer PT ( As per Form 16 / Form 12 B) -
29 Previous Employer Income Tax Deducted ( As per Form 16 / Form 12 B) -
G Rent Paid per month (Please mention the starting and ending month)
Address of CITY = >
30 the Premises :
Month Rent Amount Month Rent Amount Month Rent Amount
Apr-10 Aug-10 Dec-10
May-10 Sep-10 Jan-11
Jun-10 Oct-10 Feb-11
Jul-10 Nov-10 Mar-11
Total Number of Supporting documents enclosed herewith (in Numbers)
Verification
I do hereby declare that what ever stated above is true and correct to the best of my knowledge and belief and also undertake to indemnify the company
for any loss / liability that may arise in the event of the above information being incorrect.
* Indicates Mandatory fields
Date: Employee Signature
Place:
( Please refer overleaf for guidelines )