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s4xfe o_lval & soNs, JAL.
pH.
:24s783iti s(nctog
certiricate under
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source from income
chargeable
under the head
,'Salaries,,
1. aggregate amount deductibte under section
goc
shall not exceed one lakh rupees
2' aggregate amount deductible under the three sections, i.e., 8oc. Soccc and e0ccD, shall not enceed one takh rr rnees
Name and address of the Employer
Name and designation of the Employee
PAN/GIR NO.
TAN
PAN/GIR NO.
Acxnowteogement N0s. ot all qu?.rterly
statements of TDS under sub_section
(3) of section 200 as provided by TIN Faciliation Centre of NSDL web_site
Period
Assessment Year
Quarter Acknowledgement
No.
From
I ro
Gross Salbry
(a)
Salary as per provisions
contained in sec. 17(1)
(b) Value of prequisties
u/s 17(21
(as per Form No. 12 BA; wherever appilcable)
(o) Profits in lieu of salary under section
.l
ZiS)'
(as per Form No. 12BA, wherever applicable)
(d) Total
Rs.
2.
?
4.
Balance (1-2)
Deductions :
(a) Entertainmenl Allowance
(b) Tax on Employment.
Aggregdte of 4 (a) and (b)
Income chargeable under
the head'Salaries' (3-5) 1
5.
b.
Rs.
Rs.
Add : Any other income repo,i'ted by the empJoyee
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Gross
Amount
Rs.
i
Rs.
Rs.
Deductible
-
_Amount
ls.
ls.
ls.
Rs.'
L Gross total income (6+7)
9. Deduction under Chapter VIA
(A) Sections 80C, 80CCC and 80CCD
Gross AmoLnt
Deductible Amount
(a)
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(b)
(c)
Sectign 80C
Section 80CCC
Section 80CCD
(B) Other Sections (for e.9., 80E, 80G etc.)
,
under Chapter VIA
(a) section
(b) section
(c) section
(d) section
(e) section
10. Aggregate of deductible amounts under
11.
12.
i3.
14.
15.
16.
17.
18.
Deductible Amounl
Rs.
Rs.
Be.
Rs.
Rs.
Rs.
Rs
Rs.
Rs.
Rs.
Chapter Vl-A
Total Income (8-10)
Tax orr total income
Surcharge (on tax computed at S.No. 12)
Education Cess
(on
tax at S.No. 12 and
surcharge at S.No. 13)
Tax payable (12+13+14)
Relief under section 89 (attach details)
Tax pa;rable (15-16)
Less : (a) Tax deducted at source u/s 192 (1)
(b) Tax paid by the employer on behalf of the
employee u/s 192 (1A) on perquisites u/s
17(2)
Tax payable/ref undable (1 7-1 8)
Rs.
Rs"
Rs.
19
I ................ ....."............Son of...........".......,........., .. of working in the capacity of
(designation) do hereby Certify that a sum ot Rs........".
has been deducted at source and paid to the credit of the Central Governent. I f urther certily that the information
gtven above is true and correct based on the books ol accounts, documents and other available records.
"'.i'f '..'1 ":""r''li """"' """
Signature of the
person responsible for deduction ol tax
FullName... ..............:....
Gross Amounl ino Amounl
Rs.
Rs.
Date on which
tax deposited
(dd/mm/yy)
Transfer
voucher/challan
ldentification No.
Desr9nation.....................................
i....