5/11/2021

"FORM NO.12BB (See rule 26C)"

Statement showing particulars of claims by an employee for deduction of tax under section 192

1.Name and address of Mr. Ramesh Fulachand Dorage

the employee: Flat No. 701, Wing-H, Casa Clara, Epic Palava 2, Taloja Bypass Road,
Dobmivali €, Thane, Maharashta - 421204

2.Permanent Account Number of the employee: AKEPD8612P

3.Financial year: 2021-2022

Details of claims and evidence thereof

Evidence /
Sl. No. Nature of claim Amount(Rs.)
particulars
(1) (2) (3) (4)
1. House Rent Allowance:
(i) Rent paid to the landlord 0
(ii) Name of the landlord
(iii) Address of the landlord
(iv) Permanent Account Number of the landlord
Note: Permanent Account Number shall be
furnished if the aggregate rent paid
during the previous year exceeds one lakh rupees
2. Leave travel concessions or assistance 0
3. Others
Number Of School Going Children 2
Medical Bills 15000
4 (i). Deduction of interest on borrowing:
(i) Interest payable/paid to the lender 7
(ii) Name of the lender Bank of Baroda
(iii) Address of the lender Saikrupa Society
Shop No.2 To 6,
Hingwala Cros Lane,
Op. Popular Hotel,
Ghatkopar East,
Mumbai,
Maharashtra 400077
(iV) Permanent Account Number of the lender
(a) Financial Institutions(if available) AAACB1534F
(b) Employer(if available)
(c) Others
4 (ii). Deduction of interest on borrowing (Letout property/
second housing loan):
4 (iii). Deduction of interest on borrowing ( Add. Hsg loan
80EE):
5. Deduction under Chapter VI-A
(A) Section 80C,80CCC and 80CCD
(i) Section 80C
1/2
5/11/2021

Deduction under Chapter VI-A

(A) Section 80C,80CCC and 80CCD
(i) Section 80C
(a) Life Insurance Premium paid 85000
(b) Children Tuition Fees/Education Expenses 100000
(ii) Section 80CCC 0.00 80CCC Pension
Scheme
(iii) Section 80CCD 0.00 80CCD(1B)
National Pension
Scheme (NPS)
(B)Other sections (e.g. 80E, 80G, 80TTA, etc.)under
Chapter VI-A.
(a) 80D 25000.00 80D Mediclaim -
Self/ Spouse/
Dependent Children
(b) 80DDB 40000.00 80DDB Medical
treatment for specific
diseases
(c) 80D 25960.00 80D Mediclaim -
Dependants (Spouse
/ Children / Parents /
Senior Parents)
(d) 80EEA 200000.00 80EEA Additional
deduction on
Housing Loan
Interest on
Affordable Housing
(e) 80D 5000.00 80D Mediclaim -
Preventive Health
Check up (Senior)
Verification
I, Mr. Ramesh Fulachand Dorage , son/daughter of Fulachand Aba Dorage do hereby certify that
the information given above is complete and correct.
Place
Date 11/05/2021 (Signature of the employee)
Full Name : Mr. Ramesh Fulachand
Designation : Senior Structures Expert – UG
Dorage

2/2