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
Amount
deducted in
respect of
Total amount of life Total
house rent insurance amount of
allowance, Value of premium, tax
Total conveyance perquities provident deducted
amount of allowance and and fund during the
salary other allowances amount of contribution, year
TAN of Permanent excluding to the extent accretion etc., to (enclose
the Account amounts chargeable to tax to which certificate
employer Number of required to [See Sec 10(13A) employee's Sec.80C issued
Name and (s) as the be shown read with Rule 2A provident Total of applies under
address of alloted employer Period of in column and Section fund Columns, (Give Section
Sno employer (s) by ITO (s) employment 7&8 10(14)] account 6, 7 & 8 details) 203 Remarks
1 2 3 4 5 6 7 8 9 10 11 12

Signature of the employee

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______________________

Signature of the employee