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Annexure - I

Reimbursement on the basis of money receipt/s, bills and vouchers furnished by the under
mentioned hospitals will not be perquisite for the purpose of section 17(2) of the I.T. Act.
List of Hospital recognized under Central Govt. Health Scheme and/or approved by Chief
Commissioner of Income Tax:
Govt. Hospitals
DELHI :
1. Dr. R.M.L Hospital
2. Safdarjung Hospital
3. Smt. Sucheta Kripalani Hospital (only for maternity
and for staff working in the Hospital)
4. C.G.H.S. Maternity and Gyane Hospital, R.K. Puram
5. C.G.H.S. Maternity Centre, Srinivaspuri

6. C.G.H.S. Maternity Centre,Kalkaji


7. All centres under New Delhi Municipal Committee
(only for Maternity cases )
8. All centres under Municipal Corpn. of Delhi
(only for Hospital Maternity cases)
9. Badshah Khan Hospital, Faridabad

Private Hospitals
1. Dr. B.L. Kapur Memorial
2. St. Stephen's Hospital,
3. Kasturba Hospital, near Jama
Masjid
4. Giridhari Lal Maternity
Ajmeri Gate
5. Delhi Neurological Research
Centre (for CT Scan)
For TB only
6. Lala Ram Swarup TB
Hospital, Meharauli
7. Rajan Babu TB Hospital
Kingsway camp for
For By-Pass Surgery
8. Escorts Heart Institute
9. Batra Hospital
10. Natural Heart Institute
For General cases:
11. Narinder Mohan Hospital,
Mohan Nagar, Ghaziabad

AHMEDABAD
1. Government Civil Hospital
2. Govt. Mental Hospital
3. Govt. T.B. Hospital
4. Govt. Dental Hospital
5. Sh. M.P. Shah Cancer Hospital (Govt. aided)
ALLAHABAD
1. S.R.N. Hospital
2. M.L.N. Hospital
3. M.D. Eye Hospital
4. Dufferin Hospital
5. T.B. Sapru Hospital
6. Kamla Nehru Memorial Hospital
7. S.N. Children Hospital

BANGALORE
1. Bowring & Lady Curson
2. Central Leprosarium Magadi Rd.
3. HSIS Gosha Hospital, Taskar Town
4. Isolation Hospital, Old Madras Rd.
5. Lady Willingdon & T.B. Demonstration Training
Centre, K.G. Road
6. Minto Opthalmic Hospital, Albert Victoria Road
7 SDS Sanatorium, Hosur Road
8. T.B. Sanatorium, Old Madras Rd.
9. Vani Vilas Hospital, Krishnarajendra Road
10. Victoria Hospital
11. Sri Jayachamarajendra Institute of Indian Medicine, Tank Bund Road
BOMBAY (MUMBAI)
1. J.J. Hospital
2. St. George Hospital
3. G.T. Hospital
4. Cama Alblese Hospital
5. N.M. Mental Hospital
6. Municipal Hospitals (three)
7. Railway Hospital
8. Naval Hospital
Govt. Hospitals
CALCUTTA
1. S.S.K.M Hospital
2. Medical College & Hospital
3. N.R.S medical College & Hospital
4 R.G. Kar Medical College & Hospital
5. Polyclinic at Subushan Hospital
6. Diagnostic and Research Centre
7. National Medical College
8. K.S. Roy T.B. Hospital

1. Bombay Hospital
2. Nanavati Hospital
3. Radhibai Vatumal Sanatorium
4. Sarvodaya Hospital
5. Tata Memorial Hospital
6. Children Orthopaedic Hospital
7. National Hospital
8. Mangal Anand Hospital
Private Hospitals
1. Behala Hospital
2. Ramkrishna Mission Seva Pratisthan
3. Lumbini Park Mental Hospital
4. Belle Vue Clinic
5. Heart Care Centre
6. East India Clinic
Approved by the Chief Commissioner
of Income Tax
7. B.M. Birla Heart Research
8. Calcutta Medical Research Inst.
9. Gramma Centari Health Care Pvt. Ltd.
10. Woodland Hospital & Medical
11. Advance Medicare & Research Inst.Ltd
12. Ruby General Hospital
13. Peerless Hospital
14. Appollo Hospital
15. Kothari Medical Centre
16. Susruta Clinic & Research Institute for
Adv. Medicine
17. North City Hospital & Neuro Institute
Pvt. Ltd.

HYDERABAD
1. Osmanaia General Hospital
2. Gandhi Medical Hospital, Secundrabad
3. ENT Hospital
4. Quarantime Fever Hospital
5. Govt. Maternity Hospital

1. C.C. Shroff Hospital


2. Sagarlal Memorial Hospital
3. Sai Ram Hospital
4. Sharvana Nursing Home

Approved by the Chief Commissioner


6. Nizam Orthopedic Hospital
of Income Tax
7. Niloufer Hospital
5. Apollo Hospital (Decan Hospitals
8. Mental Hospital
Corpn. Ltd.)
9. Cancer Hospital
10. Osmania Dental College
11. T.B. Hospital
12. Sarojini Eye Hospital
13. Govt. Ayurvedic Hospital
14. Govt. Unani Hospital
JAIPUR
1. Indian Red Cross Society Polyclinic (for tests only)
1. S.M.D. Hospital
2. S.M.S. Zanana T.B. and Mental Hospital
KANPUR
1. L.L.R Hospital
2. U.I.S.E Hospital
3. U.H.M Hospital
4. A.H.M. Hospital
5. K.P.M. Hospital
6. M.I. Chest Hospital
7. J.K. Cancer Institute
8. L.L.R. Cardiology Institute
LUCKNOW
1. Civil Hospital
1. Ramkrishna Mission Vivekananda Polyclinic
2. Balrampur Hospital
2. U.P. Medical Centre (for CT Scan)
3. Medical College Hospital
MADRAS
1. Govt. Stanle, Medical College Hospital
1. Public Health Centre
2. Govt. Kulpauk Medical College Hospital
2. Andhra Mahila Sabha Nursing Home
3. Govt. General Hospital
3. Cancer Institute
4. Govt. Royapettah Hospital
Approved by the Chief Commissioner
5. Govt. Mental Hospital
of Income Tax
6. Govt. Ophthalmic Hospital
4. The Institute of Cardio-Vascular Disease
7. Govt. R.S.R.M. Hospital
Unit of Madras Medical Mission
8. Govt. Kasturba Gandhi Hospital
5. Malar Hospitals Ltd.
9. Govt. Thuruvatteswarar T.B. Hospital
6. Apollo Hospitals Enterprise Ltd.
10. Govt. T.B. Sanatorium, Tambaram
7. Sankar Nethralaya
11. Govt. Chest Institute's Tuberculosis
8. Medical Research Foundation
Demonstration and Training Centre, Chetput
12. Institute of obstetric and Gynaecology and Hospital for
women and children
13. Institute of Child Health and Hospital for Children
14. Govt. Homeopathic Medical College and Hospital
15. Govt. Peripheral Hospital, K.K. Nagar

Govt. Hospitals
MEERUT
1. P.L. Sharma Hospital
2. Medical College Hospital
3. Dufferin Hospital
NAGPUR
1. Medical college Hospital
2. Mayo General Hospital
3. Dental College and Hospital
4. Mental Hospital
PATNA
1. Patna Medical College & Hospital
2. Nalanda Medical College
3. Patna City Govt. Hospital
4. Rajendranagar Hospital
PUNE
1. Sasson General Hospital
2. Anud Chest Hospital
3. Mental Hospital, Yerwada

Private Hospitals

1. Mure Memorial Hospital


2. Matri Sewa Sangha Maternity
3. Gopikrishna Toori Neurological Clinic
4. Rashtra Sant Tukdoji Cancer Hospital
5. Nagpur Neurological Research Centre (for CT Scan)
1. Kurjee Holy Family Hospital

1. K.E.M. Hospital
2. Ruby Hall Clinic
3. Hardikar Hospital
4. N.M. Wadia Hospital
5. Sancheti Hospital
6. Joshi Hospital
7. Sarda Clinic
8. Colony Nursing Home
9. Sanjeevan Hospital
10. Pune Hospital & Research Centre
11. Nature Cure Institute, Urli, Kanchan

Referral Hospitals (with the approval of Director, C.G.H.S):


1. All India Institute of Medical Sciences, New Delhi
2. G.B. Pant Hospital, New Delhi
Specialised Hospitals (with approval of Director, C.G.H.S):
1. Tata Memorial Hospital, Bombay
2. CMC Vellore (for Neurology)
3. Mental Hospital, Ranchi (Bihar)
4. Eyes Hospital, Sitapur (U.P.)
5. Railway Hospital, Perambur
Prescribed diseases as referred in Para-13(a)
a) Cancer
b) Tuberculosis
c) Acquired Immunity Deficiency Syndrome;
d) Disease or ailment of the Heart, Blood, Lymph Glands, Bone Marrow Respiratory system,
Urinary system, Liver, Gall Bladder, Digestive system, Endocrine Glands or the Skin, requiring
surgical operation
e) Ailment or disease of the Eye, Ear, Nose or Throat, requiring surgical operation
f) Fracture in any part of the skeletal system or dislocation of vertebrae requiring surgical operation
or orthopaedic treatment
g) Gynaecological or Obstetric ailment or disease requiring surgical operation, caesarean operation
or Laperoscopic intervention

h) Ailment or diesease of the organs mentioned at (d), requiring medical treatment in a hospital for at
least three continuous days
i) Gynaecological or obstetric ailment or disease requiring medical treatment in a hospital for at
least three continuous days
j) Burn injuries requiring medical treatment in a hospital for at least three continuous days
k) Mental disorder - Neurotic or Psychotic - requiring medical treatment in a hospital for at least
three continuous days
l) Drug addiction requiring medical treatment in a hospital for at least seven continuous days
m) Anaphylectic shocks including insulin shocks, drug reactions and other allergic manifestations
requiring medical treatment in a hospital for at least three continuous days.

Annexure-II
Deduction in respect of expenses for dependant who is a person with disability u/s 80DD
and in case of a person with disability u/s 80U
i)

(a)
(b)
(c)

(d)
(e)

(f)
(g)
(h)
(i)
(j)

A person with disability means a person suffering from not less than 40% of any of
the disabilities certified by a medical authority;
ii)
Disability means: (a) Blindness, (b) Low vision, (c) Leprosy-cured, (d) Hearing
impairment, (e) Locomotor disability including cerebral palsy, (f) Mental retardation,
(g) Mental illness
iii)
Severe disability means a person with 80% or more of one or more disabilities;
iv)
Medical authority means any hospital or institution specified for the purposes of this
Act by notification by the appropriate Government. Medical Authority presently
means Medical Board duly constituted by the Central and State Government
consisting of at least three members out of which at least one shall be a specialist in
the particular field for assessing the disability. The Medical Board shall, after due
examination give a permanent Disability Certificate in cases of such permanent
disabilities where there are no chances of variation in the degree of disability. The
Board shall indicate the period of validity in the certificate, in cases where there is
any chance of variation in the degree of disability.
Blindness means total absence of sight or visual acuity not exceeding 6/60 or 20/200 (snellen) in
the better eye with correcting lenses, or limitation of field or vision subtending an angle of 20
degree or worse.
Low vision means a person with impairment of visual functioning even after treatment or standard
refractive correction but who uses or is potentially capable of using vision for the planning or
execution of a task with appropriate assistive device.
Leprosy-cured means any person who has been cured of leprosy but a suffering from loss of
sensation in hands or feet as well as loss of sensation and paresis in the eye and eye-lid but with
no manifest deformity and paresis but having sufficient mobility in their hands and feet to enable
them to engage in normal economic activity. Extreme physical deformity as well as advanced age,
which prevents him from undertaking any gainful occupation.
Hearing impairment means loss of sixty decibels or more in the better ear in the conversational
range of frequencies;
Loco motor disability means disability of the bones, joints or muscles leading to substantial
restriction of the movement of the limbs or any form of cerebral palsy. Cerebral palsy means a
group of non-progressive conditions of a person characterized by abnormal motor control posture
resulting from brain insult or injuries occurring in the pre-natal, pre-natal or infant period of
development;
Mental retardation means a condition of arrested or incomplete development of mind of a person
which is specially characterized by sub normality of intelligence;
Mental illness means any mental disorder other than mental retardation;
Autism
Cerebral Palsy
Multiple Disability

N.B. Where the condition of disability requires reassessment after a period stipulated in the
certificate, no deduction under the sections shall be allowed after its expiry unless a new certificate is
submitted from the Medical Authority

Annexure - III
(Sec rule 26B)
Form for sending particulars of Income under Secion 192(2B) for the
year ending 31st March, 20..
1.
2.
3.

Name and address of the employee


Permanent Account Number
Residential status

:
:
:

4.

Particulars of income under any head of


income other than `Salaries' (not being
a loss under any such head other than the
loss under the head `Income from House
Property') received in the financial year.
i) Income from house property (in case of
loss, enclose computation thereof)

Rs......

ii) Profits and gains of business or profession

Rs......

iii) Capital gains


iv) Income from other sources (a) Dividends
(b) Interest
(c) Other Incomes (specify)

Rs......
Rs.....
Rs.....
Rs.....
TOTAL

Rs.....

5. Aggregate of sub-items (i) to (iv) of item 4


6. Tax deducted at source (enclose certificate/s
issued under sec. 203)
Place....

________________________
Signature of the employee

Date .......
Verification
-----------I, ........... do hereby declare that what is stated above is true to the best of my knowledge and belief.
Verified today, the _______ day of ___________ 20___.
Place________
Date _________

_________________________
Signature of the employee

Annexure - IV
Comprehensive Illustration
Mr X, an officer of ABC Bank Ltd. was posted at Delhi from 01.04.2013 to 31.07.2013. He was
then transferred to Kolkata. He retired from service on 31.01.2014 after completion of 34 years seven
months of service. The Pay and Allowances received by him during the period up to the date of retirement
was as under:
Basic Pay
:
Rs. 2,20,000.00
Dearness Allowance
:
Rs. 60,000.00
H.R.A. (for 6 months)
:
Rs. 9,000.00
Special/Officiating Allowance
:
Rs. 3,000.00
C.C.A
:
Rs. 3,600.00
Closing Allowance
:
Rs.
600.00
Conveyance Allowance
:
Rs. 1,800.00
Rs. 2,98,000.00
1.
During his tenure at Delhi he stayed in an accommodation provided by the Bank. The monthly
standard rent realized from his salary amounted to Rs.200/-.
2.
After being transferred to Calcutta he put up in a rented house at a monthly rent of Rs.3,000/- for 3
months after which he shifted to his own house. He has produced rent receipt to the employer for
claiming deduction.
3.
His regular Provident Fund amounted to Rs.22,000/-. He also made a voluntary contribution of
Rs.20,000/-.
4.
He has invested a sum of Rs.10,000/- in Tax Savings Term Deposit Scheme of United Bank of
India.
5.
He paid installments of Rs.12,000/-towards repayment of Housing Building Loan. Out of the total
repayment, Rs.8,000/- was towards 1st time HBL and Rs.4,000/- towards housing loan for
renovation.
6.
He has paid tuition fee of Rs.10,000/- & Development fee of Rs.3,000/- to the school for his son,
besides Rs.12,000/- as tuition fee paid to the College for his only daughter.
7.
Reimbursement of medical bill for treatment of family members at Lake Nursing Home, Kolkata
was provided by the Bank up to Rs.35,000/-. A sum of Rs.10,000/- was also reimbursed for his
own treatment at one Govt. Hospital at Kolkata. Moreover, he received reimbursement of
Rs,2,500/- on the basis of self-declaration.
8.
He paid by cheque of Rs.7,000/- to Vanumati Agency for effecting health insurance for himself
and his family member with New India Assurance Co. Ltd.
9.
He visited Goa alongwith his wife and son by availing LFC. He made the outward journey by Air
and got reimbursement of Rs.21,000/- towards air fare. He performed the inward journey by taxi
and train and got reimbursement of Rs.10,000/- while A.C. First Class fare for the said distance is
Rs.7,500/10.
He submits a declaration of medical expenses for treatment of his disabled son along with medical
certificate and claimed relief for Rs.35,000/-. He also made deposit for Rs.20,000/- for
maintenance of disabled son under specified scheme of LICI.
11.
He availed leave encashment facilities on retirement equivalent to 8 month's salary amounting to
Rs.1,45,000/- of which Rs.1,35,000/- is exempted from tax.
12.
He got gratuity of Rs.3,50,000/- on retirement. The same was covered by payment of Gratuity Act,
1972.
13.
He paid Profession Tax of Rs.1200/-.
14.
During the year apart from NSC interest of Rs.14,455/-, he earned interest on bank deposit for
Rs.11,000/15.
He contributed Rs.10,000/- to Public Provident Fund.
16.
He contributed Rs.1,000/- to Maharashtra Chief Minister's Relief Fund. He also donated Rs.1000/to Ram Krishna Mission.
17.
Pension for February paid to him amounts to Rs.6,000/-.
18.
He has commuted 1/3rd pension for Rs.1,75,000/-.
19.
He has claimed deduction of Rs.3000 being interest on HBL & Housing loan through submission
of Form 12C and Interest Certificate.
N.B. Components of salary and figures stated herein are all hypothetical.

Computation of Income Tax on Salary for the Assessment Year 2014-15


(Amount in Rs.)
Basic Pay

220000.00

D.A.

60000.00

HRA

9000.00

Special Allowance

3000.00

C.C.A.

3600.00

Closing Allowance

600.00

Conveyance Allowance (1800-1800)

0.00

Exemption for HRA: Least of the following is exempted


Actual HRA received for 3 months

4500.00

Excess of rent paid over 10% salary (9000-6690)

2310.00

50% of salary

33450.00

(-) 2310.00

Total

293890.00

Total

299890.00

Pension

6000.00

Perquisite
Amount of actual reimbursement of LFC (21000+10000)

31000.00

Less: Exempted (21000+7500)

(-)28500.00

2500.00

Housing Accommodation:(from Apr to July)


(220000+3000+3600+600=227200/10*4=90880;
90880*15%=13632-800(4 months rent realized in Delhi)

12832.00

Leave Encashment on retirement

145000.00

Less: Exempted amount

(-) 135000.00

Medical Perquisite(35000+10000+2500)

47500.00

Less: Exempted amount (10000+15000)

(-) 25000.00
Total

10000.00
22500.00
347722.00

Other Income:
Interest on NSC

14455.00

Interest on Bank Deposit

11000.00
Gross Total Income

25455.00
373177.00

DEDUCTIONS
Professional Tax

1200.00

Interest on Housing Loan

3000.00

Donation to Prime Minister's Relief Fund u/s 80G

1000.00

Mediclaim (not paid directly to Insurance company)u/s 80D

NIL

Deduction on maintenance including medical treatment of


disabled son u/s 80DD

50000.00

Deduction under 80C (Eligible amount 1 lac)


PF Contribution (22000+20000)
HBL Installment(1st time)
NSC Interest

42000
8000
14455

Tuition Fee

22000

Tax Savings Term Deposit

10000

Contribution to PPF

10000
Total: 106455

100000.00

(-) 155200.00

NET TAXABLE INCOME

217977.00

ROUNDED OFF

217980.00

Computation of Tax
Tax up to Rs.250000/- (Senior Citizen)

NIL
TAX TO BE REALISED

0.00

Commuted value of 1/3rd of the Pension is not taxable. Installment for 2nd time HBL availed after occupation
of House Property not considered. Tuition Fee (not development fee) is available up to two children. Deduction
for donation to Ram Krishna Mission is to be claimed through personal return. Payment in respect of
Mediclaim has not been made directly, hence disallowed.

10

Annexure-V
Declaration of Tax Savings Investment and other information for claiming Income Tax
Rebate
Financial Year 2013-14
S.P.F. No
To be submitted to
Head of the Branch/ Office

Submitted by
Name:
PAN:
Designation:
Department:

I do hereby give following declaration towards payment/investments made/proposed to be made by me during the
period 1st April 2013 to 31st March 2014 to enable me to avail of tax rebate as per amended provisions of the
Income Tax Act, 1961 (as amended up to date):
Sl.No.
1.

2.
2.1

Nature of deduction claimed


Related particulars
Rate of Monthly Rent:
House Rent Rebate u/s 10(13A)
(Rent receipt is to be enclosed.
Receipt should contain name and full address of Period: fromto
the landlord)
Total Rent paid/likely to be paid: Rs.
Rebate allowable u/s.80C
(The aggregate amount of deduction u/s.80C, 80CCC and 80CCD must not exceed one lakh rupees)
Certain common investments u/s.80C are listed below.
Premium paid on Life Insurance Policies (Restricted to 10% of sum assured on each policy, 15% in
case of policy on the life of any person with disability or severe disability u/s 80U or suffering from
disease or ailment as specified u/s 80DDB)

Policy No.

Sum assured (Rs.)

Annual Premium(Rs.)

2.2 NSC VIII Issue: (Purchased/Proposed to be purchased during F.Y. 2013-14)


Date of Purchase
Certificate No.

Date of Maturity

Amount (Rs.)

11

2.3. Interest on NSC VIII Issue


Date of Purchase on or Certificate No.
after 01.04.2006

2.4.

2.5.
2.6.
2.7.
2.8.
2.8.1.

2.9.
2.10.
2.11.
2.12.
3.
3.2
4.
5.

Face Value

Unit Link Insurance Plan (ULIP)


Certificate / Policy /Receipt/Account No. and date

Amount (Rs.)

Amt.of Subscription
(Rs.)

15 year PPF
Rs.
Pension fund set up by mutual fund notified by Central Government
Rs.
Equity linked savings
Rs.
Repayment of Principal against loan for Construction or purchase of
residential house
House Building Loan:
Rs.
Amount paid towards principal only during the year
Rs.
Outstanding balance as on 01.04.2013
Rs.
EMI of HBL
Housing Loan :
Principal part of the installments paid during the F.Y.
Rs.
EMI
Rs.
Date of Availing Housing Loan
Date:
Please mention whether HBL and UHL are taken together (Please tick)
Please mention whether UHL/Housing Loan has been availed for
purchasing second housing property (Please tick)
Tuition fees
Amount deposited in 5 year time deposit scheme in Post Office
Tax Savings Term Deposit in a Bank
Any other Deposit u/s.80C (Please specify)
Deduction u/s.80D in respect of medical insurance premium (upto a
maximum limit of Rs.15000, Additional amount of Rs.5000 for Senior
Citizen).
Deduction u/s.80D for preventive health check-up (upto Rs.5000, within
the overall limit as stated above)
Deduction u/s.80DD for medical treatment of disabled dependent or
contribution to approved fund for maintenance of dependent with LICI or
any other Insurer or any other specified company
Deduction u/s.80G in respect of Donation to specified funds

YES/NO
YES/NO
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.

12

6.

Deduction u/s.80U in case of disability of specified nature of the


employee
Deduction u/s.80E towards payment of interest on Education Loan during
the F.Y. 2013-14
Deduction u/s.80TTA for interest earned from savings account (subject to
a maximum limit of Rs.10,000)
Deduction u/s. 80CCG for investment in Rajiv Gandhi Equity Saving
Scheme
Adjustment of Loss under the head Income from House property
a) Interest on loan for acquiring / construction of House and
not let out
Date of Loan

7.
8.
9.
10.

Rs.
Rs.
Rs.
Rs.
Rs.
Date:

b) Interest of loan for repairing, renovation, extension of Rs.


existing house already acquired by taking an earlier loan
Date:
Date of availing existing loan
Date:

Date of availing Original loan


11.

Deduction u/s 80EE for interest on loan taken for acquisition of


residential house property:
a) Date of sanctioning loan (the loan is to be sanctioned during Date:
01.04.13 to 31.03.14)
Rs.
b) Amount of loan sanctioned (should not exceed Rs. 25 lacs)
Rs.
c) Value of the property (should not exceed Rs. 40 lacs)
1. The employee should not own any other residential house property
2. The deduction u/s 80EE is available for interest payable on the above
loan or Rs. 1 lac whichever is less.
3. The total interest payable will first be adjusted under Income from
House Property as stated under point no. 10 above subject to overall
limit of Rs. 1.50 lac for self occupied property. The interest payable
remaining after adjustment with income from house property is to be
claimed u/s 80EE subject to maximum limit of Rs. 1.00 lac.
I do hereby declare that the aforesaid information given by me is true. I further undertake to report any change
of the above information by a separate letter addressing heads of the branches / offices.
I do also undertake to submit copies of original receipts, documents, certificates in support of the investments
proposed by me in the aforesaid declaration.
I do also declare that no one else except me has claimed the aforesaid deductions.

Date:

Signature of the employee


S.P.F. No.

13

ANNEXURE-VI

Form No.16
[See rule 31(1) (a)]
PART A
Certificate under Section 203 of the Income Tax Act, 1961 for Tax deducted at source on salary
Certificate No.

Last updated on
Name and address of the Employer:

PAN of the Deductor

Name and address of the Employee

TAN of the Deductor

CIT(TDS)

PAN of the Employee

Employee Reference No.


provided by the Employer
(if available)

Assessment Year

Period with the Employer

Address.

City. Pin code

From

To

Summary of amount paid/credited and tax deducted at source thereon in respect of the employee
Quarter (s)

Receipt Numbers of original


statements of TDS under subsection (3) of section 200

Amount paid/credited

Amount of tax deducted


(Rs.)

Amount of tax
deposited/remitted
(Rs.)

Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total (Rs.)
I. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH BOOK ADJUSTMENT
(The deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)
Sl. No.
Tax Deposited in respect
of the deductee
Book Identification Number (BIN)
(Rs.)
Receipt Numbers of
DDO serial number in
Date of transfer voucher
Status of matching
Form No. 24G
Form no. 24G
(dd/mm/yyyy)
with Form no. 24G
Total (Rs.)
II. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN
(The deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)
Sl. No.

Tax Deposited in respect of


the deductee
(Rs.)

Challan Identification Number (CIN)


BSR Code of the
Bank Branch

Date on which Tax


deposited
(dd/mm/yyyy)

Challan Serial
Number

Status of matching with


OLTAS*

1
2
3
4

14

5
6
7
8
9
10
11
12
Total (Rs.)
Verification
I, son/daughter of .. working in the capacity of . (designation) do hereby certify that a sum of Rs.
[Rs.. (in words) has been deducted and a sum of Rs.
[Rs.] has been deposited to the credit of the
Central Government. I further certify that the information given above is true, complete and correct and is based on the books of account, TDS
statements, TDS deposited and other available records.
Place
Date

(Signature of the person responsible for deduction of Tax)

Designation:

Notes:
1.
2.
3.
4.

Full Name

Part B (Annexure) of the certificate in Form No. 16 shall be issued by the employer.
If an assessee is employed under one employer during the year, Part A of the certificate in Form No. 16 issued for the
quarter ending on 31st March of the financial year shall contain the details of tax deducted and deposited for all the
quarters of the financial year.
If an assessee is employed under more than one employer during the year, each of the employers shall issue Part A of the
certificate in Form No. 16 may be issued by each of the employers or the last employer at the option of the assessee.
To update PAN details in Income Tax Department database, apply for PAN change request through NSDL or UTITSL.

15

PART B (Annexure)
Details of Salary paid and any other income and tax deducted
1.Gross Salary
(a) Salary as per provisions contained in sec.17(1)
(b) Value of perquisites u/s 17(2) (as per Form No.12BA,wherever applicable)
(c) Profits in lieu of salary under section17(3) (as per Form No.12BA,wherever applicable)
(d) Total
2. Less: Allowance to the extent exempt under section 10
Allowance

Rs
Rs
Rs
Rs
Rs

Rs
Rs
Rs

3.Balance (1-2)
4.Deductions:
(a) Entertainment Allowance
(b) Tax on Employment
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
Income

Rs
Rs
Rs
Rs

Rs

Rs.

Rs
8.Gross Total Income (6+7)

Rs

9. Deduction under Chapter VIA


(A) Section 80C, 80CCC and 80CCD
(a)

section 80C

(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)

Deductible
Amount

Gross Amount
Rs
Rs
Rs
Rs
Rs
Rs
Rs

.
.
.
.
.
.
.

(b) section 80CCC


(c) Section 80CCD

Rs
Rs

Rs
Rs

Qualifying amount

Deductible
amount

Note 1. Aggregate amount deductible under section 80C shall not exceed one lakh
rupees.
2. Aggregate amount deductible under the three sections, i.e., 80C, 80CCC, and 80CCD shall
not exceed one lakh rupees.
(B) Other sections (e.g. 80E, 80G etc.) under Chapter VI-A
Gross amount

(i)
(ii)
(iii)
(iv)
(v)

.
.
.
.
.

Rs
Rs
Rs
Rs
Rs

Rs
Rs
Rs
Rs
Rs

Rs
Rs
Rs
Rs
Rs

10.Aggregate of deductible amount under chapter VI-A

Rs

11. Total income (8-10)


12. Tax on total income
13. Education Cess @ 3% (on tax computed at S.No.12)
14. Tax payable (12+13)
15. Less:Relief under section 89 (attach details)
16. Tax Payable (14-15)

Rs
Rs
Rs
Rs
Rs
Rs
Verification

I .. son/daughter ofworking in the capacity of.(designation) do hereby certify that the


information given above is true, complete and correct and is based on the books of account, documents, TDS statements, TDS
deposited and other available records.
Place
Date

Signature of the person responsible for deduction of tax

Designation:

Full Name:

Annexure - VII
Form No.12BA
[See rule 26A (2) (b)]
Statement showing particulars of perquisites, other fringe
benefits or amenities and profits in lieu of salary with value thereof
(1) Name and address of employer:
(2) TAN:
(3) TDS Assessment Range of the
employer:
(4) Name, designation and PAN of
employee:
(5) Is the employee a director or a
person with substantial interest in
the company (where the employer is
a company):
(6) Income under the head salaries of
the employee (other than from
perquisites):
(7) Financial Year:
(8) Valuation of Perquisites:
SL.
No.

(1)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Nature of perquisite
(see rule 3)

(2)
Accommodation
Cars/Other automotive
Sweeper, gardener, watchman or
personal attendant
Gas, electricity, water
Interest free or concessional loans
Holiday expenses
Free or concessional travel
Free meals
Free education
Gifts, vouchers, etc.
Credit card expenses
Club expenses
Use of movable assets by employees
Transfer of assets to employees
Value of any other
benefit/amenity/service/privilege
Stock options (non-qualified options)
Other benefits or amenities

Value of
perquisite
as per rules
(Rs.)
(3)

Amount,
if any
recovered
from the
employee
(Rs.)
(4)

Amount of
perquisite
chargeable
to tax
Col. (3) Col. (4)
(Rs.)
(5)

18.
19.

Total value of perquisites


Total value of Profits in lieu of salary
as per section 17(3)

(9) Details of tax, (a) Tax deducted from salary of the employee under
section 192(1)
(b) Tax paid by employer on behalf of the employee
under section 192(1A)
(c) Total tax paid
(d) Date of payment into Government treasury

-------------------------------------------------

Declaration by Employer

I...s/o..
working
as

(designation) do hereby declare on behalf of United Bank of India (Branch/Office) that the
information given above is based on the books of account, documents and other relevant
records or information available with us and the details of value of each such perquisite are in
accordance with section 17 and rules framed there under and that such information is true and
correct.
Signature of the person responsible
for deduction of tax
Place:
Date:

Full Name.
Designation ..