Annexure – B

Form No 12C
[See rule 26B]

Form for sending particulars of Income under section 192 (2B) for the Financial Year ending
31st March, 2022

1 Name of the Employee Praveen Mohanraj

2 PAN BHJPM8619Q

3 Residential Status Indian

4 Particulars of Income under any head other than “Salaries” received in the FY 2021-22
(i) Interest on Securities -
(ii) Income from House Property (Including Loss) 0
(iii) Profits and Gains in Business or Profession -
(iv) Capital Gains -
(v) Income from other sources
(a) Dividends -
(b) Interest -
(c) Other incomes (Specify) -
Aggregate from (i) to (v) -

5 TDS [enclose certificate(s) issued under section 203] -

Place : Rajakkamangalam
Date : 15/01/2022

Verification

I, Praveen Mohanraj do hereby declare that

whatever is stated hereabove is true and complete to the best of my knowledge and belief.

Verified today, the 15 day of January 2021-22

Place : Rajakkamangalam
Date : 15/01/2022
(Signature)