EMP CODE:

“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 the employee:

2. Permanent Account Number (PAN) of the employee:

3. Financial year:

Details of claims and evidence thereof

Sl. No. Nature of claim Amount (Rs.) Evidence / particulars

(1) (2) (3) (4)

1 House Rent Allowance:
(i) Rent paid to the landlord Rent receipts / RentalAgreement / Bank statement
(ii) Name of the landlord
1..
2..
3..
4..
(iii) Address of the landlord

1..

2..

3..

4..

(iv) Permanent Account Number of the landlord

1..

2..

3..

4..

Note: Permanent Account Number shall be furnished, if the aggregate

rent paid during the previous year exceeds one lakh rupees

Air tickets with Boarding pass / Bus Tickets /

2 Leave travel concessions or assistance (LTA) Train Tickets / Cab bills

3 Deduction of interest on borrowing (“Income from house property”) :

(i) Interest payable/paid to the lender
1. Interest on Let-out property (Including Pre-EMI Interest) Housing Loan certificatefrom Bank / Bank statement
2. Interest on Self Occupied (Including Pre-EMI Interest) Housing Loan certificatefrom Bank / Bank statement
(ii) Name of the lender
1..
1. …………………
2..
2. …………………
(iii) Address of the lender

1..
1. …………………

2..
2. …………………
 EMP CODE:

(iv) Permanent Account Number of the lender

1.. 1. …………………

2..
2. …………………

(a) Financial Institutions (if available)

(b) Employer (if available)
(c) Others

Deduction under Chapter VI-A

(A) Section 80C,80CCC and 80CCD
(i) Section 80C
(a) Employees Provident Fund

(b) Voluntary Provident Fund

(c) Public Provident Fund Photo Copy of passbook

(d) Children Education Expenses Photo copy of the Tuition Fees paid receipt

(e) National Savings Certificate (NSC) Photo Copy of National Saving Certificates

(f) Life Insurance Premium Photo Copy of premium receipt

(g) Housing Loan Principal Repayment Housing Loan certificate from Bank / Bank statement

(h) Others - Post Office Savings Schemes, Tax Saver Term Deposit - 5 Photo copy of the Passbook / Photo copy of the Term
years Deposit receipt

(i) Sukanya Samriddhi Scheme Photocopy of the Passbook / certificate

Photo Copy of previous year National Saving

(j) Accrued NSC Interest
Certificates

Photo copy of Payment receipt / Account statement /

(k) Mutual Funds / ULIP
Certificate / Bond

(l) Rajiv Gandhi Equity Savings Scheme (80CCG) Photo copy of the Bond certificate / statement

(ii) Life Insurance Pension Scheme (Section 80CCC) Photo Copy of premium receipt

(iii) Employees contribution towards NPS (Section 80CCD) Photo Copy of contribution NPS certificate

(B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A.

(i) Medical Insurance Premium (Sec 80D)

(ii) Medical Insurance Premium for parents (sec 80D) Photocopy of premium receipt

(iii) Medical Insurance Premium paid for Senior Citizen (Parents)

(iv) Medical for Handicapped Dependents (Sec 80DD)

Photocopy of certificate / original medical bills / Form
10IA
(v) Medical for Handicapped Dependents (severe disability) (Sec 80 DD)

(vi) Medical for Specified Diseases (Sec 80DDB)

Scan copy of certificate / Original medical bills
(vii) Medical for Specified Diseases for Senior Citizen (Sec 80DDB)

(viii) Interest Paid on Higher Education Loan (Sec 80E) Bank Certificate / Statement / Financial Institution
Original paid receipt of Prime Minister National
(ix) Donation for Approved Fund and Charities (Sec 80G) Relief Fund / Chief Minister National Relief Fund

(x) Interest on House Property - Additional Exemption Bank Certificate / Statement / Financial Institution

(xi) Deduction for Permanent Disability (Sec 80U) Photocopy of Medical certificate / Form 10IA

(xii) Interest On Deposits In Saving Accounts (80TTA)

Verification

I,………………….., son/daughter of………………….. …………...do hereby certify that the information given above is complete and correct

Place:

Date: (Signature of the employee)

Designation: Full Name: