FORM NO.

12B
[See rule 26A]
Form for furnishing details of income under section 192(2) for the year ending 31st March, 20__
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
Total amount of deducted in
house rent respect of life Total amount
Value of
Total amount allowance, insurance of tax
perquisites and
TAN of the Permanent of salary conveyance deducted
Name and amount of Total of premium,
S. employer(s) as Account excluding allowance and during the
address of accretion to columns 6, 7, provident fund Remarks
No allotted by the Number of the amounts other allowances to contribution, year (enclose
employer(s) Period of employee's and 8
ITO employer(s) required to be the extent etc., to which certificate
employment provident fund
shown in chargeable to issued under
account (give sec. 80C †
columns 7 and tax[See section section 203)
details in the applies (Give
8 10(13A) read with
Annexure) details)
rule 2A and section
10(14)]
1 2 3 4 5 6 7 8 9 10 11 12

Signature of the employee

† With effect from 1-4-1991, section 80C has been replaced by section 88.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
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
Name of the TAN/PAN of the Cost of furniture (including television
employee employer Perquisite value of Value of perquisite
sets, radio sets, refrigerators, other
Where Value as if furniture (10% of Rent, if any, (column 3 minus
household appliances and air- Total of columns 4
accommodation is accommodation is column 5) OR paid by the column 8 or column 7
conditioning plant or equipment) OR and 6
unfurnished unfurnished actual hire employee minus column 8 as
hire charges, if hired from a third
charges payable may be applicable)
party
1 2 3 4 5 6 7 8 9
 ANNEXURE
(Contd.)

Estimated value of any other

Whether any conveyance Value of free or benefit or amenity provided
has been provided by the Remuneration paid concessional by the employer, free of cost Interest credited to the
employer free or at a by employer for passages on home or at concessional rate not assessee's account in
Employer's contribution to
concessional rate or where domestic and/or leave and other included in the preceding recognised provident
recognised provident fund in Total of columns 9 to 15
Name of the the employee is allowed the personal services travelling to the columns (give details), e.g., fund in excess of the
excess of 10% of the carried to column 8 of
employee use of one or more motor provided to the extent chargeable supply of gas, electricity or rate fixed by the
employee's salary [See Form No. 12B
cars owned or hired by the employee (give to tax (give details) water for household Central Government
Schedule IV - Part A]
employer, estimated value of details) [See rule [See rule 2B read consumption, free educational [See Schedule IV -
perquisite (give details) [See 3(g)] with section facilities, transport for family, Part A]
rule 3(c)] 10(5)(ii)] etc.[See rules 3(d), 3(e) and
3(f)]
1 10 11 12 13 14 15 16

Signature of the employee ____________________