Ecode : 10006980

FORM NO.12BB
(See rule 26C)
Statement showing particulars of claims by an employee for deduction of tax under section 192
Bhawna
1) Name and address of employee Maruti Apartments, WZ-721/6, Flat 103, Puran Nagar,
Maruti Chawk, Palam Colony

2) Permanent Account Number (PAN) of the employee AYLPB9224E

3) Financial year 2023 - 2024

Details of claims and evidence thereof

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

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

1 House Rent Allowance:

Rent receipts / Rental

(i) Rent paid to the landlord 780000.00
Agreement / Bank statement

(ii) Name of the landlord

1. Pushpa Devi

(iii) Address of the landlord

1. WZ 721/6, Flat 103, Puran Nagar, Palam Colony New

Delhi 110045

(iv)Permanent Account Number of the landlord

1. AIYPD6602K

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 0.00

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) 0.00

Housing Loan certificate

2. Interest on Self Occupied (Including Pre-EMI Interest) 200000.00
from Bank / Bank statement

Financial Institutions (if available)

Name of the Financial Institutions

DHFL

PAN of the Financial Institutions

AAACD1977A

Address of the Financial Institutions

Office: HDIL Towers, 6th Floor, Anant

Kanekar Marg, station road, Bandra,
Mumbai

Deduction under Chapter VI-A

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

(i) Section 80C

Employees Provident Fund (Auto populated through

103644.00
payroll)

Public Provident Fund 50000.00 Photo Copy of passbook

Photo Copy of premium

Life Insurance Premium 24593.00
receipt
 Ecode : 10006980

Housing Loan certificate

Housing Loan Principal Repayment 75703.00
from Bank / Bank statement

(ii) Life Insurance Pension Scheme (Section 80CCC) 0.00

(iii) Employee's contribution towards NPS (Section 80CCD) 0.00

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

Photocopy of premium
Medical Insurance Premium (Sec 80D) 24913.00
receipt

Photocopy of premium
Medical Insurance Premium for parents (Sec 80D) 24914.00
receipt

VERIFICATION

I Bhawna son/daughter of _____________________________________________________ do hereby certify that the information given above is complete and

correct

Place :

Date : (Signature of the employee)

Designation : LEAD - TECHNOLOGY Full Name: Bhawna .