Form No. 10-1
(See Rule 11DD)

*Certificate of prescribed authority for purposes of section 80DDB

1. Name of the patient

2. Address

3. Name and detail of the disease / ailment (please see rule 11DD)

4. The date of commencement of treatment

5. Identification Marks: 1.
2.

VERIFICATION

I certify that the information furnished above is true to best of my knowledge and the patient is suffering from abovementioned chronic and protracted disease as defined as Section 80DDB of income- Tax Act, 1961 read with the 11DD of income –Tax Rules, 1992.

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Signature

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(Name and Address)

*For persons suffering from dementia and parkinsons diseases