FORM NO.

12BB
(See rule 26C)

Priyanko Chatterjee_x000D_
10, Madan Mitra Lane; PO Beadon Street; Kolkata -
700006
1. Name and address of the employee:
2. Permanent Account Number of the employee: AHFPC0925N

3. Employee ID 90001482

4. Financial year: 2016-17

Details of claims and evidence thereof

Sl No. Nature of claim Amount (Rs.)
(1) (2) (3)
1 House Rent Allowance:
(i) Rent paid to the landlord
(ii) Name of the landlord
(iii) Address of the landlord
(iv) Permanent Account Number of the landlord

Note: Permanent Account Number shall be furnished if

the aggregate rent paid during the previous year
exceeds one lakh rupees

2 Leave travel concessions or assistance 11,737

3 Deduction of interest on borrowing:
(i) Interest payable/paid to the lender
(ii) Name of the lender
(iii) Address of the lender
(iv) Permanent Account Number of the lender
(a) Financial Institutions(if available)
(b) Employer(if available)
(c) Others
4 Deduction under Chapter VI-A
(A) Section 80C,80CCC and 80CCD
(i) Section 80C
(a) Life Insurance Premium (LIC) 12,918
(b) Public Provident Fund (PPF) 56,000
(c) ..
(d) ..
(e) ..
(f) ..
(g) ..
(ii) Section 80CCC
(iii) Section 80CCD
 (B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under
Chapter VI-A.

(i) section.
(ii) section.
(iii) section.
(iv) section.
(v) section.
Verification
I, Priyanko Chatterjee, son of Samar Kumar Chatterjee do hereby certify that the information given above is
complete and correct.
PlaceKolkata...
Date06.03.2017.... (Signature of the employee)
Designation Senior Officer Full Name: PRIYANKO CHATTERJEE
anko Chatterjee_x000D_
Madan Mitra Lane; PO Beadon Street; Kolkata -
006

PC0925N
01482
6-17

ce thereof
Evidence / particulars
(4)

Yes
by certify that the information given above is

nature of the employee)

Name: PRIYANKO CHATTERJEE
 FORM NO.12BB
(See rule 26C)

1. Name and address of the employee: Mr. XYZ , Address :

2. Permanent Account Number of the employee: ABCDE1234F

3. Employee ID 9000000

3. Financial year: 2016-17

Details of claims and evidence thereof

Sl No. Nature of claim Amount (Rs.)
(1) (2) (3)
1 House Rent Allowance:
(i) Rent paid to the landlord 10000/- p.m
(ii) Name of the landlord Mr. ABCD
(iii) Address of the landlord
(iv) Permanent Account Number of the landlord XYZEF9234L

Note: Permanent Account Number shall be furnished if the

aggregate rent paid during the previous year exceeds one lakh
rupees

2 Leave travel concessions or assistance

3 Deduction of interest on borrowing: (Interest on House loan)

(i) Interest payable/paid to the lender 200000/-
(ii) Name of the lender (Bank Name)
(iii) Address of the lender
(iv) Permanent Account Number of the lender
(a) Financial Institutions(if available)
(b) Employer(if available)
(c) Others
4 Deduction under Chapter VI-A
(A) Section 80C,80CCC and 80CCD
(i) Section 80C
(a) LIC
(b) PPF
(c) House Loan Principal
(d) Tution FEES
(e) NSC
(f) Mutual Fund
(g) Any Other
(ii) Section 80CCC
(iii) Section 80CCD (NPS)
(B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A.
 (i) section 80D (personal Mediclaim & Health Check up)
(ii) section 80E (Interest on Education Loan)
(iii) section.
(iv) section.
(v) section.
Verification
I, XYZ..,son/daughter of Mr. LMN.. do hereby certify that the information given above
complete and correct.
Place KOLKATA
Date 09/02/2017.... (Signature of the employee)
Designation SR Manager.. Full Name
XYZ , Address : Remarks
DE1234F
0000
6-17

eof
Evidence / particulars
(4)

Wish to avail Exemption : Yes / NO

Exemption will given if Supportings submit, and Exemption available in a parti
 No Required to declare the Co 'S Group Mediclaim premium

by certify that the information given above is

nature of the employee)

Name
emption available in a particular Block