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 : Ankit Raj Singh

2.Permanent Account Number of the employee : DCHPS6923N
3.Financial year : 2022-23

Details of claims and evidence thereof

Sl. Nature of claim Amount Evidence / particulars
No. (Rs.)
(1) (2) (3) (4)
1. House Rent Allowance:
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
(i) Section 80C

(ii) Section 80CCC

(iii) Section 80CCD

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

5. Deduction under Section 24

Verification
I, Ankit Raj Singh son/daughter of Dhirendra Kumar do hereby certify that the information given above is complete and correct.
Place:
Date: 23-Jan-2023 (Signature of the employee)
Designation: Software Development Engineer II Full Name: Ankit Raj Singh
 Atlassian India LLP
POI for the period of Apr 2022 To Mar 2023

Name : Ankit Raj Singh Employee No : 121548

Date Of Join : 01 Aug 2022 Permanent Account Number : DCHPS6923N

Sl.No Month Location Rent per month Approved Status Remarks

Indicator (Rs.) Amount

Sl.No Particulars Amount Approved Status No Proof Remarks

(Rs.) Amount of
Doc
Deduction Under Section 24
Previous Employment Salary
1 Education Cess 0.00 PENDING 2 Yes Previous employment - Adobe and Uber
2 Income after Exemptions 1,140,593.00 PENDING 2 Yes Previous employment - Adobe and Uber
3 Profession Tax -PT 1,000.00 PENDING 2 Yes Previous employment - Adobe and Uber
4 Provident Fund -PF 44,251.00 PENDING 2 Yes Previous employment - Adobe and Uber
5 Surcharge 0.00 PENDING 2 Yes Previous employment - Adobe and Uber
6 Tax On Income 177,859.00 PENDING 2 Yes Previous employment - Adobe and Uber
7 Total Tax 177,859.00 PENDING 2 Yes Previous employment - Adobe and Uber

Note: