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.