Sample Company Limited.

Form 16
Employee Name : DILEEP SINGH
Employee PAN : SAMPL1111E
Employee Serial Number : 103

Assessment Year : 2019-20

Financial Year : 2018-19

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 Part B (Annexure)

Details of Salary paid and any other Income and tax deducted Rs. Rs. Rs.
1. GROSS SALARY
(a) Salary as per provisions contained in section 17(1) 9,50,000.00
(b) Value of perquisites under section 17(2) 55,000.00
(as per Form No. 12BA, wherever applicable)

(c) Profits in lieu of salary under section 17(3) 0.00

(as per Form No. 12BA, wherever applicable)
(d) Total 10,05,000.00
(e) Reported total amount of salary received from other employer(s) 45,000.00
2. Less: Allowances to the extent exempt under section 10
(a) Travel concession or assistance under section 10(5) 2,000.00
(b) Death-cum-retirement gratuity under section 10(10) 4,500.00
(c) Commuted value of pension under section 10(10A) 5,000.00
(d) Cash equivalent of leave salary encashment u/s 10(10AA) 15,000.00
(e) House rent allowance under section 10(13A) 15,000.00
(f) Amount of any other exemption under section 10 5,000.00
Total amount of exemption claimed under section 10 46,500.00

3. Total amount of salary received from current employer 9,58,500.00

4. Less: Deductions under section 16

(a) Standard deduction under section 16(ia) 40,000.00
(b) Entertainment allowance under section 16(ii) 500.00
(c) Tax on employment under section 16(iii) 2,400.00
[Link] amount of deductions under section 16 [4(a)+4(b)+4(c)] 42,900.00

6. Income chargeable under the head "Salaries" [(3+1(e)-5] 9,60,600.00

7. Add: Any other income reported by the employee u/s 192 (2B)
(a) Income (or admissible loss) from house property 1,00,000.00
reported by employee offered for TDS
(b) Income under the head Other Sources offered for TDS 80,000.00
[Link] amount of other income reported by the employee [7(a)+7(b)] 1,80,000.00

9. Gross total income (6+8) 11,40,600.00

10. Deductions under Chapter VI-A

Gross Amount Deductible Amount
(a ) Deduction in respect of life insurance premia, contributions to 1,00,000.00 1,00,000.00
provident fund etc. under section 80C
(b ) Deduction in respect of contribution to certain pension 15,000.00 15,000.00
funds under section 80CCC
(c ) Deduction in respect of contribution by taxpayer to pension 20,000.00 20,000.00
scheme under section 80CCD (1)
(d ) Total deduction under section 80C, 80CCC and 80CCD(1) 1,35,000.00 1,35,000.00
(e ) Deductions in respect of amount paid/deposited to notified 5,000.00 5,000.00
pension scheme under section 80CCD (1B)
(f ) Deduction in respect of contribution by Employer to pension 3,000.00 3,000.00
scheme under section 80CCD (2)
(g ) Deduction in respect of health insurance premia u/s 80D 0.00 0.00
(h ) Deduction in respect of interest on loan taken for higher 500.00 500.00
education under section 80E

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 Gross Amount Qualifying Amount Deductible Amount

(i ) Total Deduction in respect of donations to 1,000.00 1,000.00 1,000.00

charitable institutions, etc. u/s 80G
(j ) Deduction in respect of interest on deposits 1,500.00 1,500.00 1,500.00
in savings account under section 80TTA
(k ) Amount deductible under any other provision(s) of Chapter VI‐A
80CCG - Rajiv Gandhi Equity Saving Scheme 0.00 0.00 0.00
80DD - Handicapped Dependents 0.00 0.00 0.00
80DDB - Medical Expenses, Chronic Diseases 2,500.00 2,500.00 2,500.00
80EE - Interest on Loan for House Property 1,500.00 1,500.00 1,500.00
80GG - Rent paid (HRA not received) 0.00 0.00 0.00
80U - Permanent Physical disability 0.00 0.00 0.00
(l ) Total of amount deductible under any other provision(s)
4,000.00
of Chapter VI‐A

11. Aggregate of deductible amounts under chapter VI-A 1,50,000.00

[10(d) + 10(e) + 10(f) + 10(g) + 10(h) + 10(i) + 10(j)+10(l)]

12. Total taxable income (9-11) 9,90,600.00

13. Tax on total income 1,10,620.00

14. Rebate under section 87A, if applicable 0.00

15. Surcharge, wherever applicable 0.00

16. Health and education cess 4,424.80

17. Tax payable (13+15+16-14) 1,15,044.80

18. Less: Relief under section 89 0.00

19. Net tax payable (17-18) 1,15,044.80

20. Less: TDS Deducted by Employer 5,000.00

21. Tax Payable / Refundable 1,10,044.80

Verification
I Ram Kumar , son/daughter of D Kumar working in the capacity of Manager do hereby certify that the information given above is true, complete
and correct and is based on the books of account, documents, TDS statements, and other available records.

Place : Mumbai (Signature of person responsible for deduction of tax)

Date : 18/04/2019 Full Name: Ram Kumar

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 FORM NO. 12BA
{See Rule 26A(2)(B)}
Statement showing particulars of perquisites, other fringe benefits or
amenities and profits in lieu of salary with value there of

1. Name and Address of the Employer : Sample Company Limited.

: 410,Tulsiani Chambers
: Nariman Point,Mumbai
: Mumbai,Maharashtra,400021
2. TAN : MUMI1122Z
3. TDS Assessment Range of the Employer : Nariman Point
4. Name of Employee : DILEEP SINGH
Designation : Manager
PAN : SAMPL1111E
5. Is the Employee a Director or a with substantial : NO
interest in the company (Where the employer is a company)
6. Income under the Head "Salaries" of the Employee : 950000.00
(Other than from perquisites)
7. Financial Year : 2018-19
8. Valuation of perquisites
Value of perquisite Amount,if any, recovered Amount of Taxable
Sr. No. Nature of perquisite
as per rules(Rs.) from employee(Rs.) perquisite(Rs.)
1 Accommodation 9,000.00 9,000.00 9,000.00
2 Cars/Other automotive 800.00 800.00 800.00
3 Interest free or concessional loans. 1,000.00 1,000.00 1,000.00
4 Free Meals. (Food Coupons Taxable ) 2,000.00 2,000.00 2,000.00
5 Loan_Perks 850.00 850.00 850.00
6 Total Value of Perquisites. 13,650.00 13,650.00 13,650.00
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9. Details of Tax
a) Tax Deducted from Salary of Employee u/s 192(1) 30,000.00
b) Tax Paid by Employer on behalf of Employee u/s 192(1A) 0.00
c) Total Tax Paid 30,000.00
d) Date of Payment into Government Treasury Refer Form 16

DECLARATION BY EMPLOYER
I, Ram Kumar Son / daughter of D Kumar working as Manager do hereby declare on behalf of Sample Company Limited. that the information given above is
based on the books of account, documents and other relevant records or information available with us and the details of such perquisite are in accordance
with section 17 and rules framed there under and that such information is true and correct.

For Sample Company Limited.

Signature of the person responsible for deduction of tax

Place: Mumbai Full Name Ram Kumar
Date: 18/04/2019 Designation Manager

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 SALARY ANNEXURE
Details of Salary Paid and Allowance Exempted u/s 10 and 17(2) of Income-tax Act,1961

1. Name and address of the Employer : Sample Company Limited.

: 410,Tulsiani Chambers
: Nariman Point,Mumbai
: Mumbai,Maharashtra,400021
2. Name of Employee : DILEEP SINGH
Designation : Manager
PAN : SAMPL1111E
Employee Serial No. : 103

Salary for the period : 01/04/2018 to 31/03/2019

1. Salary as per provisions contained in Sec 17(1)
Basic Salary 7,50,000.00
Medical Allowance 1,00,000.00
Medical Exempt under proviso to sec. 17(2) 50,000.00
Leave Encashment 25,000.00
Other Allowances 20,000.00
Flat Allowance 5,000.00

Total Salary (A) 9,50,000.00

Value of perquisite u/s17(2) 55,000.00
(as per Form No.12BA wherever applicable)
Profit in lieu of Salary u/s 17(3) 0.00
(as per Form No.12BA wherever applicable)

Total Perquisites (B) 55,000.00

Gross Salary (A+B) 10,05,000.00

2. Details of Allowance exempted u/s 10 and 17(2)

HRA 16,500.00
Conveyance Allowance 20,000.00
LTC 8,000.00
Daily Allowance 2,000.00
Total (C) 46,500.00
3: Balance : (A+B-C) 9,58,500.00

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