FORM NO.

12BB
(See Rule 26C)
Statement showing particulars of claims by an employee for deduction of tax under section 192

1. Employee Code : W0622

2. Name of employee : Gaurahari Rana
3. Permanent Account Number of the employee : ARQPR8911G
4. Financial year 2018-19

Details of claims and evidence thereof

Sl Nature Amount (Rs.) Evidence / particulars
No. of claim
(1) (2) (3) (4)
1 House Rent Allowance:
(i) Rent paid to the landlord 98400
(ii) Name of the landlord Ms. Pratima
C.Chandankar
(iii) Address of the landlord A 504 Enclave Socity,
Donapula Goa
(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

3 Deduction of interest on borrowing:
(i) Interest payable/paid to the lender 241,004
(ii) Name of the lender IDBI Limited
(iii) Address of the lender Marigold House Plot No-
A-34-Cross Road No-2
Marol Midc Andri-E
Mumbai-
(iv) Permanent Account Number of the lender AABC18842G
(a) Financial Institutions(if available)
(b) Employer(if available)
(c) Others

4 Deduction under Chapter VI-A

(A) Section 80C,80CCC and 80C
(i) Section 80C
(a) 241,004 Housing Loan Principal Rep Certificate Attached
(b) Life Insurance Premium 182703
(c) Children Education Fee (Tuition Fees)
20075
(d) Deposit In Post Office Tax Saving Scheme

(e) Housing Loan - Principal amount

repayment only 76866
(f) Fixed Depost with Scheduled Bank for a
period of 5 years or more 0
(g)
(ii) Section 80CCC
(iii) Section 80CCD
(B) Other sections (e.g. 80E, 80G, 80TTA, etc.)
under Chapter (i) VI-A.
section……………….
(ii) section……………….
(iii) section……………….
(iv) section……………….
(v) section……………….

Verification
I, Gaurahari Rana hereby certify that the information given above is complete and correct.

Place Goa
Date 16.1.2020

Designation..Style Manager Full Name.. Gaurahari Rana