FORM NO.

12B
[See rule 26A]
Form for furnishing details of Income under section 192[2] for the year ending 31st March, 2017

Name and address of the employee 0

Permanent Account No. 0

Residential status 0

Particulars of salary as defined in section 17,

paid or due to the employee during the year
Total amount
of house rent Value of
allowances to perquisites
Total amount the extent and amountof
of salary chargeable to accretion to Amount deduction
excluding tax [see exmployees in respect of life Total amount of
Permanent amounts section provident Insurance premium tax deduction
TAN of the Account required to be 10(13A) read fund fund during the
employer( Number of shown in with rule 24 account[give Total of contribution,which year(enclose
Serial Name and address s) allotted theEmployer(s Period of colums 7 and and section details in the columns 6,7 section80C applies certificate under Professional Tax
Number of the employer(s) by the ITO ) employement 8 10[(14)] Annexure) and 8 (Give details) section 2(13) deduction Remarks
1 2 3 4 5 6 7 8 9 10 11 12 13

From :
1 0 0 0 0 0 0 0 0 0 0
To :

.
Signature of the employee

Verification

I, .. do hereby declare that what is stated above is true to the best of my knowledge and belief.
Verified today, the .. day of .. 2016 /17

.
Place : Signature of the employee
 ANNEXURE
[See column 8 of Form No. 12B]

Particulars of value of perquisites and amount accretion to employee's provident fund account

Name and address of the employee 0

Permanent Account No, 0

Name TAN/PAN of the Value of rent-free accomodation or value of any concession in rent for the accomodation provided by Whether any Remuneration Value of free or Estimated value Employ Interest Total of
of the employer Where Where accomodation is furnished Rent, if any, Value of conveyance has paid by employer concessional of any other ers credited columns
employ accomoda Value as if Cost of Perquisite Total of paid by the perquisite been provided by for domestic passages on benefit or contribu to the 9 to 15
ee tion is accomodation furniture value of columns 4 employee (column 3 the employer free and/or personal home leave and amenity provded tion to assessee' carried to
unfurnish is unfurnished (including furniture and 6 minus column or at a concessional services provided other travelling by the employer, recogni s account columns
ed television sets, (10% of 8 or column 7 rate or where the to the employee to the extent free of cost or at zed in 8 of Form
radio sets, column 5) OR minus column employee is (give details) chargeable to concessional rate provide recognize No. 12B
refrigerators, actual hire 8 as may be allowed the use of [See rule 3(g)] tax (give not included in nt fund d
other household charges applicable) one or more moter details) [See the preceding in provident
appliances and payable cars owned or hired rule 2B read columns (give excess fund in
air-conditioning by the employer, with section details), e.g., of the excess of
pland or estimated value of 10(5)(ii)] supply of gas, rate the rate
equipment) OR perquisite (give electricity or fixed by fixed by
hire charges, if details) [See rule water for the the
hired from a 3(c.)] household Cnetral Central
third party consumption, free Govern Governm
education facilit ment ent [See
[See Schedule
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

0 0
0

________________________________
Signature of the employee

Verification

I, , do hereby declare that what is stated above is true to the best of my knowledge and belief.

Verified today, the ________________ day of ____________________, 2016/17

Place :
________________________________
Signature of the employee