FORM NO.

16
[See rule 31(1)(a)]
Certificate under section 203 of the Income-tax Act, 1961 for tax deducted at source
from income chargeable under the head "Salaries"
Name and Address of the Employer Name and Designation of the Employee
SECRETARY TO GOVERNMENT XXXXXXXXXXXX
FINANCE DEPARTMENT YYYYYYYYYYYYYYYYYYYYY
SECRETARIAT, CHENNAI-600 009. FINANCE DEPARTMENT
PAN No. of the Deductor TAN No. of the Deductor PAN No. of the Employee
CHET 08887 E ACLPA6072B
Acknowledgement Nos.of all quaterly statements of TDS under
sub-section (3) of section 200 as provided by TIN Facilitation Period Assessment Year
Centre or NSDL web-site.
Quarter Acknowledgement No. From To
1st Quarter - April - June
2nd Quarter - July - Sept
3rd Quarter - Oct - Dec
01-04-2009 31-03-2010 2010-2011
4 Quarter - Dec - Mar
th

DETAILS OF SALARY PAID AND ANY OTHER INCOME AND TAX DEDUCTED

1. GROSS SALARY
(a) Salary as per provisions contained in
section. 17(1) Rs. 730,076
(b) Value of perquisites u/s 17(2) (as per Form No.
12BA, Wherever applicable) Rs. -
(c) Profits in lieu of salary under section 17(3)
(as per Form No.12BA,wherever applicable) Rs. -
(d) TOTAL : Rs. 730,076
2. Less : Allowance to the extent exempt U/S 10
Allowance Rs.
HRA Exemption (Sec 10 (13A)) -
Conveyance Exemption (Sec 10(14)) -
Rs. -

3. BALANCE ( 1 - 2 ) Rs. 730,076

4. DEDUCTIONS :
(a) Entertainment allowance Rs. -
(b) Tax on Employment Rs. 2,475

5. Aggregate of 4(a) and (b) Rs. 2,475

6. Income chargeable under the head
' Salaries ' ( 3 - 5 ) Rs. 727,601
7. Add : Any other income reported by the
employee
Other incomes Rs.
Interest on housing loan(for tax exemption) -
Other income (interest, etc.) -

Rs. -

8. GROSS TOTAL INCOME ( 6 + 7 ) Rs. 727,601

9. Deductions under Chapter VI - A
(A) sections 80C, 80CCC and 80CCD
(a). Section 80C Gross Amount Deductible amount
( i ) G.P.F. (sec 80C) Rs. 120,000
( ii ) Children's Education (sec 80C) Rs. -
( iii ) Housing loan principal repayment (sec 80C) Rs. -
( iv ) Insurance premium (sec 80C) Rs. -
( v ) SPF+FBF+HBAFBF (sec 80C) Rs. 360 Rs. 120,360 Rs. 100,000
(b) Section 80CCC Rs. -
(c) Section 80CCD Rs. -
Note : 1. Aggregate amount deductible under section 80C shall not exceed one Lakh rupees.
2. Aggregate amount deductible under the three sections, i.e.. 80C, 80CCC and 80CCD, shall not exceed one lakh ruppes.
(B) other sections (e.g.,80E, 80G etc.) under chapter VIA
Gross Amount Qualifying Amount Deductible Amount
(a) Medical Insurance Premium (sec 80D) Rs. 300 Rs. 300 Rs. 300
(b) Medical for handicapped dependents (Sec 80DD) Rs. - Rs. - Rs. -
(c) Medical for specified diseases (Sec 80DDB) Rs. - Rs. - Rs. -
(d) Higher Education Loan Interest Repayment (Sec 80E) Rs. - Rs. - Rs. -
(e) Donation to approved fund and charities (sec 80G) Rs. - Rs. - Rs. -
(f) Rent deduction (sec 80GG) only if HRA not received Rs. - Rs. - Rs. -

10. Aggregate of deductible amounts under Chapter VI - A Rs. 100,300

11. TOTAL INCOME ( 8 - 10 ) Rs. 627,300

12. Tax on total income Rs. 92,190

13. Surcharge (on tax computed at S.No. 12) Rs. -

14. Education Cess @ 2% on (tax at S.No. 12 plus

surcharge at S.No. 13) Rs. 2,766

15. Tax payable ( 12 + 13 + 14 ) Rs. 94,956

16. Relief under section 89 ( attach details ) Rs. -

17. Tax payable ( 15 - 16 ) Rs. 94,956

18. Less : ( a ) Tax deducted at source u/s 192 (1) Rs. 94,956
( b ) Tax paid by the employer on behalf of the
employee u/s 192 (1A) on perquisties u/s 17 (2) Rs. - Rs. 94,956

19. Tax Payable / Refundable ( 17 - 18 ) Rs. -

DETAILS OF TAX DEDUCTED AND DEPOSITED INTO CENTRAL GOVERNMENT ACCOUNT

(The Employer is to provide transaction - wise details of tax deducted and deposited)

Date on
Education Total tax BSR Code Transfer voucher/
Sl. TDS Surcharge Cheque/DD which tax
Month Cess deposited of Bank Challan
No. No.( if any ) deposited
branch Identification No.
Rs. Rs. Rs. Rs. (dd/mm/yy)
1. March - - - - -
2. April - - - - -
3. May - - - - -
4. June - - - - -
5. July - - - - -
6. Aug. - - - - -
7. Sept. - - - - -
8. Oct. - - - - -
9. Nov. - - - - -
10. Dec. - - - - -
11. Jan. - - - - -
12. Feb. 92,190 - 2,766 94,956 -

92,190 - 2,766 94,956

I VANITHA son / daughter of MADHAVA RAO working in the capacity of SECTION OFFICER (designation) do hereby
certify that a sum of Rs. 92,190 [Rupees fourteen thousand eight hundred and fifty only (in words)] has been deducted at source
and paid to the credit of the Central Government. I further certify that the information given above is true and correct based on the
books of account, documents and other available records.

________________________________
Signature of the person responsible for deduction of tax
Place : CHENNAI
Date ### Full Name : M.VANITHA
Designation :
 INDIAN INCOME TAX RETURN Assessment Year
FORM

SARAL-II For Individuals having Income from Salary / Pension / Income from One House
Property (excluding loss brought forward from previous years) /
(ITR-1) Income from Other Sources (Excluding Winning from Lottery and Income 2 0 1 0 - 1 1
from Race Horses)]
(Please see rule 12 of the Income-tax Rules,1962) (Also see attached instructions)

First Name Middle name Last name PAN

PERSONAL INFORMATION

xxxxxx ACLPA6072B
Flat/Door/Block No. Name of Premises/Building/Village Date of Birth (DD/MM/YYYY)

Road/Street/Post Office Area/Locality Employer Category (Tick)

✘ Govt. PSU Other

Town/City/District State Pin code Sex (Tick)

TAMILNADU Male Female

Email Address (STD code) Phone Num ( 044 ) 9444925898

FILING STATUS

Designation of Assessing Officer Return filed under Section - [Please

1 1
(Ward / Circle) see instruction number 9(i)]

Whether original or Revised return? (Tick) ✘ Original Revised

If revised, enter Receipt No. and Date of filing original return (DD/MM/YYYY)
Residential Status (Tick) ✘ Resident Non-Resident Resident but Not Ordinarily Resident
1 Income chargeable under the Head 'Salaries' (Salary/Pension) 1 7,27,601
2 Income chargeable under the Head ‘House Property’ (enter –ve sign in case of loss, if any) 2 NIL
INCOME & DEDUCTIONS

3 Income chargeable under the Head ‘Other Sources’ (enter –ve sign in case of loss, if any) 3 NIL
4 Gross Total Income (1+2+3) 4 7,27,601
5 Deductions under chapter VI A (Section)
a 80C 100000 e 80DD NIL i 80GG NIL
b 80CCC NIL f 80DDB NIL j 80GGA NIL
c 80CCD NIL g 80E NIL k 80GGC NIL
d 80D 300 h 80G NIL l 80U NIL
6 Deductions (Total of 5a to 5l) 6 1,00,300
7 Total Income ( 4 - 6 ) 7 6,27,300
8 Tax Payable on Total Income 8 92,190
9 Secondary and Higher Education cess on 8 9 2766
TAX COMPUTATION

10 Total Tax and Education Cess Payable ( 8 + 9 ) 10 94,956

11 Relief under Section 89 11 NIL
12 Relief under Section 90/91 12 NIL
13 Balance Tax Payable (10 - 11 - 12) 13 94,956
14 Total Interest Payable u/s 234A / 234B / 234C 14 NIL
15 Total Tax and Interest Payable (13 + 14) 15 94,956
Do not write or stamp in this area
For Office Use only Seal and Signature of receiving official

Receipt No.

Date

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 16 Taxes Paid
TAXES PAID

a Advance Tax (from Item 25) 16a NIL

b TDS (column 7 of item 23 + column 7 of item 24) 16b 94,956
c Self Assessment Tax (from item 25) 16c NIL
17 Total Taxes Paid (16a+16b+16c) 17 94,956
18 Tax Payable (15-17) (Enter if 15 is greater than 17, else leave blank) 18 -0
19 Refund (17-16) (enter if 17 is greater than 15, also give Bank Account details below) 19 0
REFUND

20 Enter your bank account number (mandatory in case of refund)

21 Do you want refund by ✘ cheque, or deposited directly into your bank account? (tick as applicable)
22 Give additional details of your bank account
MICR Code Type of Account (Tick as applicable) Savings Current

23 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]

Deduction
TDS ON SALARY

Sl Income chargeable
Tax Deduction Account Number under Tax Payable (incl. Total tax Tax payable/
No Name and address of the Employer under the head
(TAN) of the Employer Chapter edu. cess) deducted refundable
. Salaries
VI-A

(1) (2) (3) (4) (5) (6) (7) (8)

i
ii

24 Details of Tax Deducted at Source other than salary

Sl Tax Deduction Account Date of Amount out of (6)

Name and address of the Amount Paid/
No Number (TAN) of the Payment/ Total tax deducted claimed for this
TDS ON INTEREST

Deductor Credited
. Deductor Credit year

(1) (2) (3) (4) (5) (6) (7)

i
ii
iii
NOTE ► Enter the total of column (7) of 23 and column (7) of 24 in Sl No. 16b of TAXES PAID

25 Details of Advance Tax and Self Assessment Tax Payments

Sl. Date of Deposit Serial Number of
Name of Bank & Branch BSR Code Amount (Rs.)
No (DD/MM/YYYY) Challan
TAX PAYMENTS

i
ii
iii
iv
NOTE ► Enter the totals of Advance tax and Self Assessment tax in Sl No. 16a and 16c of TAXES PAID

26 Other Information (transactions reported through Annual Information Return) (Please see instructions under 9(ii) for code)
Sl No. Code Amount (Rs.) Sl No. Code Amount (Rs.) Sl No. Code Amount (Rs.)
a 001 d 004 g 007
b 002 e 005 h 008
c 003 f 006
27 Exempt income only for reporting purposes ( from Dividend, Capital gains etc. ) 25

VERIFICATION
I, xxxxxx son/daughter of
solemnly declare that to the best of my knowledge and belief, the information given in the return thereto is correct and complete and that the amount of
total income and other particulars shown therein are truly stated and are in accordance with the provisions of the Income-tax Act, 1961, in respect of
income chargeable to Income-tax for the previous year relevant to the Assessment Year 2010-11

Place CHENNAI Date Sign here

28 If the return has been prepared by a Tax Return Preparer (TRP) give further details as below:
Identification No. of TRP Name of TRP Counter Signature of TRP

29 If TRP is entitled for any reimbursement from the Government, amount thereof (to be filled by TRP) 29

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 GOVERNMENT OF INDIA

INCOME-TAX DEPARTMENT

ACKNOWLEDGEMENT

Received with thanks from xxxxxx a return of income

and/or return of fringe benefits in Form No. ITR -1 for assessment year 2010-2011, having the following particulars.

Name PAN
PERSONALINFORMATION

xxxxxx
Flat/Door/Block Name Of Premises/Building/Village
0 0
Road/Street/Post Office Area/Locality
0 0
Town/City/District State
- TAMILNADU

1 Gross total income 1 727,601

COMPUTATION OF INCOME AND TAX THEREON

2 Deductions under Chapter-VI-A 2 100,300

3 Total Income 3 627,300

4 Net tax payable 4 94,956

5 Interest payable 5 NIL

6 Total tax and interest payable 6 94,956

7 Taxes Paid
a Advance Tax 7a Nil

b TDS 7b 94,956

c TCS 7c Nil

d Self Assessment Tax 7d Nil

e Total Taxes Paid (7a+7b+7c +7d) 7e 94,956

8 Tax Payable (6-7d) 8 -0

9 Refund (7e-6) 9 Nil

10 Value of Fringe Benefits 10 NA

COMPUTATION OF FRINGE BENEFITS

11 Total fringe benefit tax liability 11 NA

12 Total interest payable 12 NA

AND TAX THEREON

13 Total tax and interest payable 13 NA

14 Taxes Paid
a Advance Tax 14a NA

b Self Assessment Tax 14b NA

c Total Taxes Paid (14a+14b) 14c NA

15 Tax Payable (13-14c) 15 NA

16 Refund (14c – 13) 16 NA

Receipt No. Seal and Signature of the receiving official

Date
Date