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T26423 Dec 2022 FY2023119206

Tax Proof FY 22-23

RefNo:264
Employee Code 119206 Name Kumar J S

Department AMIND NPME DSM PAN CAIPS2029H

Life Insurance Premium

Declared Proof Cleared Remarks

71092 50244

Number
of Amoun
Installme t
Number nt Amoun Payabl
Name of of Payable t Paid e on or
the Installme on or on or before Total
Insuranc Date of nt Paid on before after 31st Amount FY
e Commenceme or after 31st Mar 1st Apr Mar 22-23 (Paid
Compan Policy nt Sum Premiu Frequenc 1st Apr 22 23 22(Amt 23(Amt Amt+Payabl Relationshi
y No. (dd/mm/yyyy) Assured m Amt y (Count) (Count) ) ) e Amt) p

HDFC 20094078 21/02/2018 1000000 26768 Yearly 0 1 0 26768 26768 Self

LIFE 0

LIC 61688372 28/09/2012 300000 5869 Quarterly 3 1 17607 5869 23476 Self
5

80D - Medical Insurance

Declared Proof Cleared Remarks

25000 30000

Number Amou
of Amou nt
Number Installm nt Paya
of ent Paid ble
Name Installm Payable on or on or Total
of the ent Paid on or after befor Amount
Insuran Premi on or before 1st e 31st FY 22-23
ce Co / Date um / after 1st 31st Mar Apr Mar (Paid Age
Catego Instituti (dd/mm/yy Bill Freque Apr 22 23 22(A 23(A Amt+Paya Gro Relations Mod
ry on Policy/Bill No yy) Amt ncy (Count) (Count) mt) mt) ble Amt) up hip e

Medical Practo RCPINFINITY000 31/05/2022 30000 Yearly 1 0 30000 0 30000 Belo Self / Other
Insuran 0047 w 60 Spouse / s
ce Year Children
s

Rent

Employee Code : 119206 Date : 23 Dec 2022

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Landlord
Rent Rental Other Rental Landlord Landlord Landlord Landlord Landlord Address
Month Location Location Amount Rental Address Name 1 PAN 1 Address 1 Name 2 PAN 2 2

April Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

May Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

June Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

July Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

August Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

September Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

October Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

November Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

December Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

January Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

February Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

Employee Code : 119206 Date : 23 Dec 2022

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March Others Bengaluru 25000 2, 8th B Cross, JS Savithri BKJPS3992R 16 6th Corss AGB
Nagara, Colony
Saraswathipura, Saraswahtipura
Bengaluru-560086 Bengaluru-560086

Employee Code : 119206 Date : 23 Dec 2022

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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: Kumar J S

2. Permanent Account Number of the employee: CAIPS2029H

3. Financial year: 2022 - 2023

Details of claims and evidence thereof

SI.No Nature of claim Amount Evidence / particulars

(Rs.)

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

1. House Rent Allowance:

(i) Rent paid to the landlord 300000

(ii) Name of the landlord

1. Savithri

(iii) Address of the landlord

1. 16 6th Corss AGB Colony
Saraswahtipura
Bengaluru-560086

(iv) Permanent Account Number of the landlord

1. BKJPS3992R

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

3. Deduction of interest on borrowing:

(i) Interest payable/paid to the lender

(ii)Name of the lender

(iii) Address of the lender

(iv) Permanent Account Number of the lender

(a) Financial Institutions(if available)

(b) Employer(if available)

(c) Others

4. Deduction under Chapter VI-A

(A) Section 80C,80CCC and 80CCD

Employee Code : 119206 Date : 23 Dec 2022

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(i) Section 80C

Life Insurance Premium 50244

(ii) Section 80CCC

(iii) Section 80CCD 0

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

(i) Sec 80D - Medical Insurance 30000

Verification

I, Kumar J S ,son/daughter of ____________________ do hereby certify that the information given above is complete and correct.

Place : BANGALORE
Date : 23/12/2022 (Signature of the employee)
Designation : Staff Engineer - New Product Manufacturing Full Name: Kumar J S

Employee Code : 119206 Date : 23 Dec 2022