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FORM NO.

12B
[See rule 26A]

Form for furnishing details of income under section 192(2) for the year ending 31st March, 2013
Name and address of the employee

EMP ID
..
Permanent Account No.

Residential Status

Particulars of salary as defined in section 17, paid


or due to be paid to the employee during the year
Serial

Name and address

TAN of the

Permenent

Period of

Total amount

Total amount

Value of

Total of

Amount

Total amount

Number

of employer(s)

employer(s)

Account

employment

of salary

of house rent

perquisites and

columns

deducted

of tax deducted

as allotted

Number

exculding

allowance,

amount of

6, 7 and 8

in respect

during the

by the ITO

of the

amounts

conveyance

accretion to

of life

year (enclose

employer(s)

required to

allowance and

employee's

insurance

certificate

be shown in

other allowances

provident fund

premium,

issued under
section 203)

columns 7

to the extent

account

provident fund

and 8

chargeable to

(given details

contribution,

tax [See section

in the Annexure)

etc, to which

10(13A) read

section 80C

with Rule 2A

Applies (Give

and section

details)

Remarks

10(14)
1

10

11

.
Signature of the employee
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
Signature of the employee

12

ANNEXURE
[See column 8 of Form No. 12B]

Particulars of value of perquisites and amount of accretion to employee's provident fund account
Name and address of the employee

Permanent Account No.

Name of the employee

TAN/PAN

Value of rent-free accomodation or value of any concession in rent for the accommodation provided by the employer (give basis of computation)

of the

[See rule 3(a) and 3(b)]

employer

Where accommodation is furnished


Where acco-

Value as if

Cost of furniture

Perquisite value

Total of

Rent, if any

Value of

mmodation

accummodation

(including Television

of furniture (10% of

columns

paid by the

perquisite

is unfurnished

is unfurnished

4 and 6

employee

(column 3

sets, radio sets,

column 5) OR

refrigerators, other

actual hire

minus

household appliances

charges

column 8 or

and air-conditioning

payable

column 7 minus

plant or equipment)

column 8 as

OR hire charges,if

as may be

hired from a third

applicable

party

ANNEXURE
(Contd.)
Whether any conveyance has been
provided by the employer free or at a
concessional rate or whre the employee
is allowed the use of one or more motor
cars owned or hired by the employer,
estimated value of perquisite (give
details) [See rule 3 (c )]

Remuneration paid by employer


for domestic and/or personal
services provided to the employee
(give details) [See rule 3(g)]

Value of free or
concessional
passages on home
leave and other
travelling to the
extent chargable to
tax (give details)
[See rule 2B read
with
section
10(5)(ii)]

Estimated value of any


other benefit or amenity
provided
by
the
employer, free of cost or
at concessional rate not
included in the preceding
column (give details),
e.g., supply of gas,
electricity or water for
house hold consumption,
free
educational
facilities, transport for
family, etc, (See rule
3(d), 3(e) and 3(f)]

Employer's
contribution
to
recognised providend
fund in excess of
12%
of
the
employee's
salary
(See Schedule IVPart A

10

11

12

13

14

Interest credited to Total of columns 9 to 15 carried to


the
assessee's column 8 of Form No. 12B
account
in
recognised
providend fund in
excess of the rate
fixed by the Central
Government
[See
Schedule IV - Part
A]

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