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Form No. 16 [ See rule 31 (1) (a) ]

Certificate under section 203 of the Income-tax Act, 1961 for tax deducted at source from income chargeable under the head " Salaries " Name and Designation of the Employee 1

Name and Address of the Employer

Form 24 Seq. No. : PAN / GIR No. TDS Circle where Annual Return/Statement under Sec.206 is to be filed. TAN No PAN / GIR No. Period From Assessment Year


Acknowledgement Nos. of all quarterly statements of TDS under sub-section (3) of section 200 as provided by TIN Facilitation Quarter Acknowledgement No.


1 GROSS SALARY a) Salary as per provisions contained in sec.17(1) b) Value of perquisites u/s 17(2) (as per FormNo.12BA, wherever applicable) c) Profits in lieu of salary under section 17(3) (as per Form No.12BA, wherever applicable) d) Total 2 LESS : Allowances to the extent exempt under section 10 Allowance Conveyance Allowance 3 BALANCE ( 1 - 2 ) 4 DEDUCTION (a) Tax on employment (b) Entertainment Allowance 5 AGGREGATE OF 4 ( a to b ) 6 INCOME CHARGEABLE UNDER THE HEAD SALARIES ( 3 - 5) 7 ADD Any other income reported by the employee

Rs.0 Rs.0 Rs.0 Rs.0

Amount Rs.0 Rs.0 Rs.0

Rs.0 Rs.0 Rs.0 Rs.0

8 GROSS TOTAL INCOME ( 6 + 7 ) 9 DEDUCTION UNDER CHAPTER VI - A (A) Sections 80C, 80CCC and 80CCD A. Section 80C (a) (b) (c) (d) B. Section 80 CCC C. Section 80 CCD (B) Other Sections (e.g. 80E, 80G etc.) under chapter VI A Gross Amt (a) (b) (c) (d) Rs.0 Rs.0 Rs.0 Rs.0 Qualify Amt eductible Amt D Rs.0 Rs.0 Rs.0 Rs.0

Gross Amt Deductible Amt

10 Aggregate of Deductible amount under Chapter VI - A 11 TOTAL INCOME ( 8 - 10 ) 12 TAX ON TOTAL INCOME Page 2 : 0

13 SURCHARGE ( ON TAX COMPUTED AT SR.NO.12) 14 EDUCATION CESS @ 2% ON (TAX AT S. NO. 12 PLUS SURCHARGE AT S.N 13 15 TAX PAYABLE (12+13+14) 16 Relief under section 89 (attach details) 17 Tax payable (15-16) 18 Less : (a) Tax deducted at source u/s 192(1) (b) Tax paid by the employer on behalf of the employee u/s 192(1A) on perquisites u/s 17(2) 19 TAX PAYABLE / (REFUNDABLE) ( 17 - 18 ) Rs.0 Rs.0

DETAILS OF TAX DEDUCTED AND DEPOSITED INTO CENTRAL GOVERNMENT ACCOUNT Sr.No. TDS SurchargesEducation Cess Tax Deposited DD No. Total Chq No./ BSR Code of Bank on which tax deposited (DD/MM/YY) Date Branch Transfer voucher/Challan Identific 1 2 3 4 5 6 0 0 0 0 0 0 0

7 8 9 10

0 0 0 0

I , son/daughter of working in the capacity of (Designation) do hereby certify that a sum of Rs. 0 has been deducted at source and paid to the credit of the Central Gove certify that the information given above is true and correct based on the book of accounts, documents and other available recor

Place : Date :

Signature of the person responsible for the deduction of tax. Full Name : 0 Designation : 0

Note: This form for your help only.In case of confusion, consult relevant rules and forms.

Income-tax Act,

of the Employee


200 as provided by TIN Facilitation Centre or NSDL web-site


Rs.0 Rs.0


Deductible Amt

Deductible Amt

Rs.0 Rs.0 Rs.0

0 0

Rs.0 Rs.0

Rs.0 Rs.0

Transfer voucher/Challan Identification No.

n the capacity of paid to the credit of the Central Government. I further documents and other available records

responsible for the