Employee's Income Tax Declaration Form for the Financial Year 2012-13

Name: Designation Department DOJ:

Work Permit No.

PAN No: Gender: DOB Email

Contact No.

S. No. A 1 2 3 B

DESCRIPTION Particulars of Income from sources other than salary from the NIT Raipur (optional) Dividends Interest Other Incomes (specify) Total Earnings Income from House Property Annual Value of House Property (As Per Income Tax Act) Less: (I) Standard Deduction (as per Section 24(1) (II) Interest on Housing Loan - as per Section 24(2) (for Tax Exemption - Self
Occupied Property acquired /constructed before 01-04-1999 - Rs.30,000 elgible & Self Occupied Property acquired /constructed after 01-04-1999 - Rs.150,000 eligble)

Rs.

Proposed Investment Date

a. Amount of Interest for the F.Y. 2012-13 b. Amount of Interest for Pre-Contruction Period (as per Income Tax Rule) Total Income from House Property HRA: RENT PAID PER MONTH ( Please mention the starting and ending month)
Period:

0 Rent (p.m.)

Total Rent Paid (per annum) D 1 2 3 4 5 6 7 8 9 10 11 E 1 2 3 4 5 6 7 F INVESTMENTS U/S 80C, 80CCC, 80CCD capped at Rs 1 Lac Provident Fund (PF) Employees Contribution under New Pension Scheme Public Provident Fund Contribution to Certain Pension Funds Housing Loan Repayment Principal (payable in F.Y. 2011-12) Insurance Premium (including GIS contribtuion) Term Deposit with Schedule Bank National Saving Scheme / Certificate Mutual Fund Children Education Expenses / Tuition Fees Others, (Please specify if any) Total Investments U/S 80C - limited to Rs 1,00,000/- only OTHER PERMITTED DEDUCTIONS 80D - Medical Insurance Premium (Maximum Rs. 15,000
(Rs. 20,000 for senior citizens

0 PREVIOUS EMPLOYMENT SALARY Salary Paid TDS (in Rs.) If Yes, Form 16 from previous employer or Form 12 B attached I, do hereby declare that investment(s) proposed will be completed on or before the proposed date and proof of investment(s) will be submitted by 05th February, 2013. Further, incase of any change in above declaration, I would revise it and inform the insitute immediately. I shall indemnify the institute for all cost and consequences if any information is found to be incorrect.

80DDB - Expenditure on Medical Treatment for specified disease 80E - Repayment of Interest against Educational Loan 80G - Donations (only for Prime Ministers National Relief Fund, the Chief Ministers Relief Fund or the Lieutenant Governors Relief Fund) 80GG - Rent Paid but not in Receipt of HRA 80U-Permanent Physical Disability (Normal Rs. 50000/- and Severe Rs.1,00,000/-) Others - (Please specify if any) Total Deductions

Date:

Page 1 of 4

Name with Signature of Employee

FORM NO. 12B [See rule 26A] Form for furnishing details of income under section 192(2) for the year ending 31st March,_______ Name and address of the employee Permanent Account No. Residential status Particulars of salary as defined in section 17, paid or due to be paid to the employee during the year Name and address of employer(s) TAN of the employer(s) as allotted by the ITO Permanent Account Number of the employer(s) Period of employment Amount deducted in respect of life Total amount of house rent Total of insurance premium, allowance, conveyance Value of perquisites columns 6, provident fund allowance and other and amount of contribution, etc., to allowances to the extent accretion to employee's 7, and 8 which sec. 80C chargeable to tax[See section provident fund account applies (Give details) 10(13A) read with rule 2A and (give details in the section 10(14)] details in the 7 8 9 10 Total amount of tax deducted during the year (enclose certificate issued under section 203) 11

S.No

Total amount of salary excluding amounts required to be shown in columns 7 and 8 6

Remarks

12

With effect from 1-4-1991, section 80C has been replaced by section 88. 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______________________ Place

Signature of the employee

Signature of the employee

ANNEXURE [See column 8 of Form No. 12B] Particulars of value of perquisites and amount of accretion to employee's provident fund account Name and address of the employee Permanent Account No. Period : Year ending 31st March,_______________ Value of rent-free accommodation or value of any concession in rent for the accommodation provided by the employer (give basis of computation)[See rules 3(a) and 3(b)] Where accommodation is furnished Value of perquisite (column 3 minus Rent, if any, column 8 paid by the or column employee 7 minus column 8 as may be applicable) 8 9

Name of the employee

TAN/PAN of the employer

Value as if Where accommodatio accommodation n is is unfurnished unfurnished

Cost of furniture (including television sets, radio sets, refrigerators, other household appliances and air-conditioning plant or equipment) OR hire charges, if hired from a third party

Perquisite value of furniture (10% of column 5) OR actual hire charges payable

Total of columns 4 and 6

ANNEXURE (Contd.)

Name of the employee

Interest credited to the Estimated value of any other Remuneration paid assessee's Employer's Total of by employer for Value of free or concessional benefit or amenity provided by the account in contribution to columns 9 Whether any conveyance has been provided by the employer free or domestic and/or employer, free of cost or at passages on home leave and recognised recognised provident to 15 at a concessional rate or where the employee is allowed the use of personal services other travelling to the extent concessional rate not included in provident fund fund in excess of 10% carried to one or more motor cars owned or hired by the employer, estimated the preceding columns (give provided to the chargeable to tax (give details) in excess of of the employee's column 8 value of perquisite (give details) [See rule 3(c)] details), e.g., supply of gas, employee (give [See rule 2B read with section the rate fixed salary [See Schedule of Form electricity or water for household details) [See rule 10(5)(ii)] by the Central IV - Part A] No. 12B consumption, free educational faci 3(g)] Government [See Schedule IV - Part A] 10 11 12 13 14 15 16

Name of Employee Place Signature

Signature of the employee