FORM NO.

12B
[See rule 26A]
Form for furnishing details of income under section 192(2) for the year ending 31st March,
Name of the employee Permanent Account No.

Address of the employee Residential Status

Sr. Name and address of employer(s) TAN of the Permanent Period of Particulars of salary as defined in section 17, Total of Amount Total amount Remarks
No. employer(s) Account employment paid or due to be paid to the employee during columns 6,7 deducted in of tax
as allotted by Number of the year and 8 respect of life deducted
the ITO the Total amount Total amount Value of insurance during the
employer(s) of salary of house rent perquisites premium, year (enclose
excluding allowance, and amount of provident certificate
amounts conveyance accretion to fund issued under
required to be allowance and employee's contribution, section 203)
shown in other provident fund etc., to which
columns 7 and allowances to account (give section 80C
8 the extent details in the applies (Give
chargeable to Annexure) details)
tax [See
section
10(13A) read
with rule 2A
and section
10(14)]
1 2 3 4 5 6 7 8 9 10 11 12

0.00 0.00

0.00

0.00

0.00

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

Signature of the employee

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ANNEXURE
[See column 8 of Form No. 12B]
Particulars of value of perquisites and amount of accretion to employee's fund account

Name of the employee Permanent Account No.

Address of the employee Period : Year ending

Name of the employee TAN / PAN of the Value of rent-free accommodation or value of any concession in rent for the accomodation provided by the employer(give
employer basis of computation) [See rules 3(a) and 3(b)]
Where Where accomodation is furnished Rent, if any, paid Value of
accomodation is Value as if Cost of furniture Perquisite value Total of columns by the employee perquisite
unfurnished accomodation is (including of furniture (10% 4 and 6 (column 3 minus
unfurnished television sets, of column 5) OR column 8 or
radio sets, actual hire column 7 minus
refrigerators, charges payable column 8 as may
other household be applicable)
appliances and
air-conditioning
plant or
equipment) OR
hire charges, if
hired from a third
party

1 2 3 4 5 6 7 8 9

0.00 0.00

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ANNEXURE
(Contd.)

Whether any Remuneration paid by Value of free or Estimated value of any Employer's contribution Interest credited to the Total of columns 9 to 15
conveyance has been employer for domestic concessional passages other benefit or amenity to recognised provident assessee's account in carried to column 8 of
provided by the and / or personal on home leave and provided by the fund in excess of 10% recognised provident Form No. 12B
employer free or at a services provided to the other travelling to the employer, free of cost or of the employee's salary fund in excess of the
concessional rate or employee (give details) extent chargeable to tax at concessional rate not [See Schedule IV - Part rate fixed by the Central
where the employee is [See rule 3(g)] (give details) [See rule included in the A] Government [See
allowed the use of one 2B read with section preceding columns (give Schedule IV - Part A]
or more motor cars 10(5)(ii)] details), e.g.' supply of
owned or hired by the gas, electricity or water
employer, estimated for household
value of perquisite (give consumption, free
details) [See rule 3(c)] educational facilities,
transport for family, etc.
[See rules 3(d), 3(e) and
3(f)]

10 11 12 13 14 15 16

0.00

Signature of the employee

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