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Designation : TECHNICAL ASSISTANT, DEPT. OF CA, ITER, S'O'A UNIVERSITY, BHUBANESWAR 751030 RESIDENTIAL ADDRESS Plot No.-124, Road-2, Lane-4, Shri Jagannath Vihar, Baramunda, Bhubaneswar-751003 MALE/FEMALE PAN (Mandatory) : BIEPS9271G For the Financial Year 2010-11

1. 2. 3. 4. 5. 6. 7. 8. SALARY (PAY + DA + IR + SP + DP) a) Arrear, if any b) Allowances, if any (except HRA) Value of perquisite (U/s 17 of Rule 3) Total(Sl. No. 1 + 2 + 3) Income from other sources HRA received from the employer House rent paid to the house owner Repayment of house loan Interest Principal Annual value(income from house property) Deductions to be made under Chapter-VIA of income tax act 1961 Under section 80 CCE(Aggregate amount of deduction U/s 80C, 80CCC and 80CCD shall not exceed Rs. 100,000) (a) U/S 80C i) Contribution to EPF ii) Insurance Premium iii) Subscription to Central Govt. Or any such deposit scheme (NSC) iv) ULIP, 1971 of the UTI/ULIP of LIC, Mutual Fund v) Any subscription made to any units of mutual fund vi) PPF vii) Repayment of housing building loan (principals, stamp duty, regd.) viii) Tuition fee (full time education of any two children of the employee) ix) Subscription to equity shares or debentures forming part of any issues of capital x) Subscription to notified tax saving bonds xi) Investment as a term deposit for a fixed period not less than 5 years with a scheduled bank xii)NSC(VIII issue) xiii) Others if any specify (b) U/S 80CCC (annuity plan of LIC or other insurer Maximum Rs.100,000) (c) U/S 80CCD(Contribution to Pension Scheme of Central Govt. Employee) Total [a(i - xiii) + b + c] B C D U/S 80D(payment of Medical Insurance Premium) U/S 80DD(expenditure on medical treatment of dependant with disability) U/S 80E(Repayment of interest on loan taken for the purpose of pursuing higher studies of the assessee himself or spouse or children ) E U/S 80G (Donation to certain funds for charitable purpose) F U/S 80GG (House rent paid by the assessee for his residence) G U/S 80U (in case of assessee with disability) H Under any other section(please specify) Nil Rs. 3,000 Nil Rs. 205,854 Nil Nil Nil Rs. 205,854 Nil Rs. 32,974 Rs. 54,000 Nil

9. 10. A


Rs. 3,000 Nil Nil

Rs. 54,000

1. 2. 3. 4. Gross salary (Sl. No. 4 in the above table) HRA received from the employer Total [Sl. No. 1 + Sl. No. 2] Less House rent allowance exempt U/S 10(13A) least of a) Actual amount of HRA received b) Actual expenditure incurred in payment of rent in excess of 10% of Salary (Basic + DA + DP) c) 40% of Salary (Basic + DA + DP) Balance [Sl. No. (3) Sl. No. (4)] Deduction : U/S 16(iii) (Professional Tax) Balance (Sl. No. 5 Sl. No. 6) Add/less : income/loss from house property as per form No. 12C (+/-)interest borrowed on capital Add : any other income reported by the employee Gross total income (Sl. No.7 + Sl. No.8 + Sl. No.9) Deductions under Chapter VIA of the Act Under Section 80D 80DD 80E 80G Nil Nil Nil Nil Nil Rs. 205,854 Rs. 32,974 Rs. 238,828 Rs. 32,974
Rs. 32,974 Rs. 33,415 Rs. 82,342

5 6 7 8 9 10 11 a (i) a (ii) b c d

Rs. 205,854 Rs. 1,500 Rs. 204,354 Nil Nil Rs. 204,354

20585.4 54000 33414.6

5. No. a) b) c) d) For Senior Citizen (65 Yrs.354 Rs. 91000/. 8.000 Exceed Rs.00. 19 . excess of Rs.000/- d) > Rs. 34000/.+ 20% of the Amount by which total income exceed Rs.90.00. 1. 1. 8.001 but does not exceed Rs.00.80.e f g a b c 12 13 14 15 16 17 18 19 20 21 22 80GG 80U Other Total (a to g) Under Section 80CCE 80C 80CCC 80CCD Total (a to c) Total deduction under Chapter VIA (Sl. 3.014 Rs.00.00.000 Nil Nil Rs.00.+ 30% of the Amount by which total income exceed Rs. 8.001/NIL 10% of Amt.974 Rs. 1. 5. 15 + Sl.+ 20% of the Amount by which total income exceed Rs.001 but does not exceed Rs.000 Exceed Rs. 8.Sl.00.90. 8.001/- B).000/- NIL 10% of Amt. 8.90.001 but does not exceed Rs. 13) Total of Tax Add : Education Cess + Secondary and Higher Education Cess (3% of the amount as at Sl.00.001 but does not exceed Rs.000/Rs.Sl.+ 30% of the Amount by which total income exceed Rs. 2011 Certified that the details furnished by me in this statement are correct to the best of my knowledge and belief.000 Rs. No.000 Rs. 18) Tax already deducted at Source Tax payable / Refundable (Sl.000/NIL 10% of Amt.+ 20% of the Amount by which total Rs. 3.135 Rs. No.40000 Rs. 20) Tax to be deducted in February. a) b) c) For women Where total income does not exceed Rs. 2. No. 34000/.000 Rs. 8.00. 5.00. excess of Rs. 2. 11(i)+ Sl.000 Exceed Rs. No.000/> Rs. Date : Place : Signature of the Employee Rs. 32.000/- d) > Rs. 5.000/Rs. 32. 2.000/> Rs. 10 . 2. No. 17 . 201. 16) Less : Relief U/S 89(1) when salary paid in arrear or in advance Tax payable after deduction of relief(Sl. 2.001 but does not exceed Rs.00.000/> Rs.000 Rs. 12) [Should be rounded off to the nearest multiple of ten rupees] Tax payable(on the amount as at Sl. 34000/.074 Nil Nil Nil Nil Nil Nil A). 1.00.00 but does not exceed Rs. excess of Rs. 5. No. a) b) c) Calculation of Income Tax : Where total income does not exceed Rs.00. Or More) Where total income does not exceed Rs. No.974 Nil Nil Rs.00.40. 11(ii)) Total income/taxable income (Sl. 3.80.+ 30% of the Amount by which total income exceed Rs. No. 1. No. 5.Sl. No.40.00. 8. 5. 20. 91000/.000/> Rs.001/- C). 15) Total Tax Payable(Sl. 94000/. 1. 5.000/- .00.80. No. 8.00.