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[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

Permanent Account No.

Residential status :

TAN of the Permanen Period Particulars of salary as defined section 17,

Serial Name and employer t Account of paid or due to be paid to the employee Total Amount Total Remarks
Number address of (s) as Number of employ during the year of deducted in amount of
employer(s allotted of the ment colum respect of life tax
) the ITO employer( ns 6,7 insurance deducted
s) and 8 premium, during the
provident fund year
contribution, (enclose
etc., to which certificate
section 80C! issued
applies (give under
details) section

Total Total amount Value of

amount of of house rent perquisites
salary allowance, and
excluding conveyance amount of
amounts allowance and accretion
required to other to
be shown in allowances to employees
columns 7 the extent provident
and 8 chargeable to fund
tax [See account
section (give
10(13A) read details in
with rule 2A the
and section Annexure)
1 2 3 4 5 6 7 8 9 10 11 12
Signature of the employee

I, _____________________ do hereby declare that what is stated above is true to the best of my knowledge and belief. Verified today, the _______ day of ______________

Signature of the employee

[See column 8 of Form No. 12B]

Particulars of value of perquisites and amount of accretions to employees fund account

Name and address of the employee.......................................................................................NOT APPLICABLE

Permanent Account No. ...................................................

Period: Year ending 31st March, 19 .............

Name of the TAN/PAN of Value of rent-free accommodation or value of any concession in rent for the accommodation provided by the employer (give
employee the employer basis of computation) [See rules 3(a) and 3(b)]
Where accommodation is furnished
Where Rent, if any, Value of
accommodatio paid by the perquisite(colu
n is employee mn 3 minus
unfurnished column 8 or
column 7
minus column
8 as may be
Value as if Cost of Perquisite Total of
accommodatio furniture value of columns 4 and
n is (including furniture (10% 6
unfurnished television sets, of column 5)
radio sets, OR actual hire
refrigerators, charges
other payable
appliances and
plant or
equipment OR
hire charges, if
hired from a
third party
1 2 3 4 5 6 7 8 9
Whether any Remuneration paid Value of free or Estimated value of Employers Interest credited to Total of columns 9
conveyance has by employer for concessional any other benefit or contribution to the assessees to 15 carried to
been provided by domestic and/or passages on home amenity provided by recognised account in column 8 of From
the employer free or personal services leave and other the employer, free of provident fund in recognised No. 12B
at a concessional provided to the travelling to the cost or at excess of 10% of the provident fund in
rate or where the employee (give extent chargeable to concessional rate employees salary excess of the rate
employee is allowed details) [See rule tax (give details) not including in the [See Schedule IV fixed by the Central
the use of one or 3(g)] [See rule 2B read preceding columns Part A] Government [See
more motor cars with section 10(5) (give details), e.g. Schedule IV Part
owned or hired by (ii)] supply of gas, A]
the employer, electronic or water
estimated value of for household
perquisite (give consumption, free
details) [See rule educational
3(C)] facilities transport
for family, etc., [See
rules 3(d), 3(e) and
10 11 12 13 14 15 16

Signature of the employee