Name A B C and Company

Degisnation Clerk Cum Typist

Department Account Branch
Station Rohtak
Pan Number AEYPD2706C
Sex M (Type M,W,S,SS)

TABLE "A"
[See item 7 of Annexure 1]
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Total income Salary received Total income (as Tax on total Tax on total Difference in tax
of the relevent in arrears or increased by income [as per income[as per [Amount under
previous advance salary received in column (2)- column (4) After column (6) minus
year(Rs.) relating to the arrears or After Rebate Rebate and including amount under
Previous relevent advance) of the and including Edn Cess and column (5)] (Rs.)
year previous year relevent previous Edn Cess and Surcharge] (Rs.)
as mentioned in year mentioned in Surcharge]
column (1) column (1) (Rs.) (Rs.)
(Rs.)

(1) (2) (3) (4) (5) (6) (7)

2005-06 0 0 0 0 0 0
2006-07 0 0 0 0 0 0
2007-08 0 0 0 0 0 0
2008-09 0 0 0 0 0 0
2009-10 0 0 0 0 0 0
2010-11 0 0 0 0 0 0
2011-12 1,000,000 0 1000000 156,560 156,560 0
2012-13 1,000,000 0 1000000 133,900 133,900 0
2013-14 1,341,692 0 1341692 239,483 239,483 0
TOTAL 3,341,692 0 3,341,692 529,943 529,943 0

Signature:
Name: A B C and Company
Designation: Clerk Cum Typist
Place: Rohtak Dept: Account Branch
Date: 15-10-2013

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 ANNEXURE-I
[See item 2 of Form No.10E]
Arrears or advance salary

Sl
Particulars Amount (Rs.)
No.
1 Total income (excluding salary received in arrears or advance) 1,341,692
2 Salary received in arrears or advance 0
Total income (as increased by salary received in arrears or advance) [Add
3 1,341,692
item 1 and item 2]
4 Tax on total income [as per item 3] 239,483
5 Tax on total income [as per item 1] 239,483
Tax on salary received in arrears or advance [Difference of item 4 and item
6 0
5]
Tax computed in accordance with Table "A" [Brought from column 7 of
7 0
Table A]
Relief under Section 89(1) [Indicate difference between the amounts
8 0
mentioned against item 6 and item 7]

Signature:
Name: A B C and Company

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FORM NO.10 E
[See rule 21AA]
Form for furnishing particulars of income under section 192(2A) for the year ending 31 st March, 2014 for
claiming relief under section 89(1) by a Government servant or an employee in a 2[company,co-operative
society,local authority ,university, institution,association or body]

A B C and Company, Clerk Cum Typist, Account

1 Name and address of the employee
Branch

2 Permanent account number AEYPD2706C

3 Residential status RESIDENT AND ORDINARILY RESIDENT
Particulars of income referred to in rule 21A of the Income-tax Rules, 1962,during the previous year
relevant to assessment year 2014-15 (Rs.)
1 (a) Salary received in arrears or in advance in accordance with the provisions of sub-rule (2)
0
of rule 21A.
(b)
Payment in the nature of gratuity in respect of past services, extending over a period of
…Nil…
not less than 5 years in accordance with the provisions of sub-rule (3) of rule 21A.

(c)
Payment in the nature of compensation from the employer or former employer at or in
connection with termination of employment after continuous service of not less than 3 …Nil…
years or where the unexpired portion of term of employment is also not less than 3 ye

(d) Payment in commutation of pension in accordance with the provisions of sub-rule (5) of
…Nil…
rule 21A
2 Detailed particulars of payments referred to above may be given in Annexure I,II,IIA,III, or IV as the case
may be.

Signature of the employee ……………………………………

Verification
I, A B C and Company ,do hereby declare that what is stated above
is true to the best of my knowledge and belief.
Verified today, the Day of

Plac Rohtak ………………………………………

Date 15-10-2013 Signature of the employee

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