Tax Information Network of Income Tax Department

FORM 16A
[See rule 31(1)(b)]

Certificate No : AQJAHX
Last Updated 20/04/2012

Certificate under section 203 of the Income-tax Act, 1961 for Tax deducted at source

Name and address of the Deductor THE NEW INDIA ASSURANCE COMPANY LIMITED 3128 KHADE BAZAR BELGAUM-0

Name and address of the Deductee CHOUGULE RAVINDRA ASHOK B C 65 CAMP BELGAUM KARNATAKA

PAN of the Deductor

TAN of the Deductor

PAN of the Deductee

AAACN4165C CIT(TDS)
THE COMMISSIONER OF INCOME TAX (TDS)

BLRT02204G Assessment Year

ADLPC9104B Period

From
ROOM NO. 59 H.M.T. BHAWAN

To 31/03/2012

2012-13
4TH FLOOR BELLARY ROAD GANGANAGAR BANGALORE 560032

01/01/2012

Summary of payment Amount paid/credited 5,800.00 194J - Fees for Professional or Technical Services 5,800.00 194J - Fees for Professional or Technical Services 11,600.00 Nature of payment Date of payment/credit 30/01/2012 28/02/2012 Status of Booking MATCHED MATCHED

Summary of tax deducted at source in respect of deductee

Receipt Numbers of original quarterly statements of TDS under sub-section(3) of section 200 XWIXCRJG Amount of tax deducted in respect of the deductee Amount of tax deposited/remitted in respect of the deductee 1,160.00

Quarter

Q4

1,160.00

I.DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH BOOK ENTRY (The Deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)

= Not Applicable =
II.DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN (The Deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)

Challan Identification number (CIN)

S. No. Tax Deposited in respect of the deductee (Rs.) 1 2 Total 580.00 580.00 1,160.00 BSR Code of the Bank Branch 0350039 0350039 Date on which tax deposited 03/02/2012 02/03/2012 Challan Serial Number Status of Booking

3 2

MATCHED MATCHED

Verification
I, BRANCH MANAGER, son/daughter of . working in the capacity of BRANCH MANAGER (designation) do hereby certify that a sum of Rs. 1,160.00 [ Rupees One Thousand One Hundred Sixty Only] has been deducted and a sum of Rs. 1,160.00 [Rupees One Thousand One Hundred Sixty Only ] has been deposited to the credit of the Central Government. I further certify that the information given above is true, complete and correct and is based on the books of account, documents, TDS statements, TDS deposited and other available records.

For

THE NEW INDIA ASSURANCE COMPANY LIMITED

Place : Date :

BELGAUM 26/04/2012 Signature of person responsible for deduction of tax Full Name : BRANCH MANAGER

Designation : BRANCH MANAGER