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: Deepak Payal 2. Employee Code: 15583
___________________________________________________________________________________________________ .
3. Permanent Account Number (PAN) of the employee: ASLPJ5452G
4. Financial year: 2022-23
Details of claims and evidence thereof
S.No. Nature of claim Amount (Rs.) Evidence / particulars
(1) (2) (3) (4)
1 House Rent Allowance:
(i) Rent paid to the landlord Rs. (15000*12) =180000 . from _April-2022 to Mar-2023 - Annual.
(ii) Address of premises - C508, Ramson's Kshitij Gurgaon
(iii) Name of the landlord - Ravindra
(iv) Address of the land lord
(v) Permanent Account Number (PAN) of the landlord - BXZPR2420L
Note: Permanent Account Number (PAN) of landlord shall be furnished if the aggregate rent paid during the year exceeds one Lac Rupees.
2 Leave travel concessions or assistance
3 Deduction of Interest on Housing Loan :
(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 (if available, pls Specify) : ________________________________________________________________________
4 Deduction under Chapter VI-A Amount (Rs.) Evidence / particulars
A Section 80C,80CCC and 80CCD lic
(i) Section 80C:
(a) Life Insurance Policies 6778
(b) SSA 150,000
(c) PPF -
(d) NSC -
(e) Tution Fees -
No. of School/College going children 01 & staying in Hostel : Yes / No __NO
(f) Repayment of Housing Loan -
(g) Mutual Fund/Fixed Deposit (Under Tax Saving Scheme) -
(h) Other Investments (Give Details) -
(ii) Section 80CCC (Not Applicable-clubbed with 80C) -
(iii) Section 80CCD(1B) NPS (by employee, Max limit - 50,000) -
(iv) Section 80CCD(2) NPS (through employer, max limit 10% of basic) -
(v) Section 80D (Mediclaim Policy) CARE Health Insurance

For Section 80D, max qualifying amount towards Premium paid on the health of :- a) himself, spouse & children Rs.25,000/-, in case senior citizen then
Rs.30,000/-, b) If separate premium for parents then additional amount of Rs.25,000/-, in case of parent senior citizen then Rs.30,000/-.

(vi) Section 80DD (Physical Handicapped Dependent) -

B Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A
(i) Section 80E (Interest on Loan for Higher Education) -
(ii) Section 80G (Donation if exempted 100%) -
(iii) Section 80TTA (Interest on saving bank a/c, max limit - 10,000) -
Total Interest received from saving bank account - To claim deduction u/s 80TTA
Verification

I, DEEPAK PAYAL , Son of Mr. OM PRAKASH do hereby certify that the information given above is complete and correct.

Place : Gurgaon
Date : 14.09.2022 _______________________
(Signature of the employee)
DesignManager Production Full Name : DEEPAK PAYAL