PHOTOGRAPH OF PATIENT

 
Form No.10-1
(see Rule 11DD)


*CERTIFICATE
(Under Section 80 DD)


This is to Certify that Mr./Ms./master-----------------------------------------------------------------
Son / Daughter of Mr. / Mrs.----------------------------------------------------------------------------
--------------------Whose particulars are furnished below is a bonafide dependent person who
is suffering from a permanent disability under section 80 DD of in come Tax Act 1992.

 

PARTICULARS OF THE PATIENT

1. Name of the patient                                                   :

 

2. Age                                                                            :      Years

 

3. Sex                                                                             :       Male / Years

 

4. Name and Detail of the Disease ailment
        (Please see Rule 11DD)                                        :

 

5. The date of commencement of treatment                  :

 

6. Cause of loss in functional capacity                          :

 

7. Identification Marks : 1.
                                       2.

 

 

                                                                                                  (Doctor’s Signature With Date )

 

Certification that I have actually incurred
Rs---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
My----------------------------------------------------------dependent who is suffering from permanent
disability under section 80 DD of income Tax Act 1992.

 

Date
Residence Address


                               * for person suffering from mental retardation.