I.T. (SIXTH AMEND) RULES 1961 FORM NO.

16
[See rule 31 (1) (a)] Certificate under section 203 of the Income Tax act, 1961 for tax deducted at Source from

Name and address of the employer

Name and Designation of the Employer

PAN / GIR NO. TAN PAN / GIR NO. TDS Circle where Annual Period.. Assessment Year Return/Statement Section 206 is to be filed. From To Ward - Sivasagar DETAILS OF SALARY PAID AND ANY OTHER INCOME AND TAX DEDUCTED 1. Gross Salary* .. (a) Salary as per provisions contained in section 17(1) (b) Value of perquisites under section 17(2) ,as per Form No.12 BA, (c) Profits in lieu of Salary under section 17(3) (as per Form No.12 BA, whenever applicable.) (d) Total 2. Less : Allowance to the extent exempt ...... under section 10 H.R.A. 3. Balance (1 2) 4. Deduction : (a) Standard Deduction (b) Entertainment Allowance (c) Tax on Employment 5. Aggregate of 4 (a to c) 6. Income chargeable under the head Salaries 7. Add : Any other income reported by the employee 8. Gross Total Income( 6 + 7) 9. Deduction under chapter VI A (U/S 80C/80CCC to 80U) Please Specify (a) (b) G.P.F. / C.P.F./ P.P.F. . . ..... [H.B.L.INST. Qualifying Amount Gross Amount Deductible Amount

(c) G.I.S.
(d) HBL INSTALLMENT (e) P.T. (f) NSC/ NSC ACCRUED INTEREST (g) LIC PREMIUM (h) TUTION FEES (i) PLI CONTRIBUTION (j) ULIP / MUTUAL FUND . (k) INSFRUSTRUCTURE BOND .... 10. Aggregate of deductible amount under chapter VI-A (Including deduction U/S 80C) 11. Total Income (8 10) 12. Tax on Total Income 13. Rebate & Relief under Chapter VIII 1.UNDER SECTION 88 (Please specify) 14. Aggregate of tax rebate and relief at 13 above 15. Tax payable ( 12 14 ) and surcharge thereon [Education Cess @ 2% ] 16. Less : Tax deducted at source 17. Tax Payable / refundable ( 15 16 ) DETAILS OF TAX DEDUCTED AND DEPOSITED INTO CENTRAL GOVERNMENT ACCOUNT AMOUNT DATE OF PAYAMENT NAME OF BANK & BRANCH WHERE TAX DEPOSITED

I . Son of Working in the capacity of . ( designation ) do hereby certify that a sum of Rs ( Rupees . In words) has been deducted at source and paid to the credit of the Central Government. I Further certified that the information given above is true and correct based on the books of accounts, documents and other available record. the person responsible for Signature of

Place :- ..
deduction of tax

Date : . Full Name ..

Income... Chargeable under the head Salaries.