FORM NO.

12B
[See rule 26A]

Form for furnishing details of income under section 192(2) for the year ending 31st March,
Name of the employee

Permanent Account No.

Address of the employee

Residential Status

Sr. Name and address of employer(s) TAN of the

No.
employer(s)
as allotted by
the ITO

Permanent
Account
Number of
the
employer(s)

Particulars of salary as defined in section 17,

Amount
Period of
Total of
employment paid or due to be paid to the employee during columns 6,7 deducted in
the year
respect of life
and 8
insurance
Total amount Total amount
Value of
premium,
of salary
of house rent
perquisites
provident
excluding
allowance, and amount of
fund
amounts
conveyance
accretion to
contribution,
required to be allowance and employee's
etc., to which
shown in
other
provident fund
section 80C
columns 7 and allowances to account (give
applies (Give
8
the extent
details in the
details)
Annexure)
chargeable to
tax [See
section
10(13A) read
with rule 2A
and section
10(14)]

0.00

0.00

10

Total amount
of tax
deducted
during the
year (enclose
certificate
issued under
section 203)

Remarks

11

12

0.00

0.00

0.00

Verification
I,

, do hereby declare that what is stated above is true to the best of my knowledge and belief, verified today
Signature of the employee

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ANNEXURE
[See column 8 of Form No. 12B]

Particulars of value of perquisites and amount of accretion to employee's fund account

Name of the employee

Permanent Account No.

Address of the employee

Period : Year ending

Name of the employee

TAN / PAN of the

employer

Value of rent-free accommodation or value of any concession in rent for the accomodation provided by the employer(give
basis of computation) [See rules 3(a) and 3(b)]
Where
Rent, if any, paid
Value of
Where accomodation is furnished
accomodation is
perquisite
Value as if
Cost of furniture Perquisite value Total of columns by the employee
unfurnished
(column 3 minus
of furniture (10%
4 and 6
accomodation is
(including
column 8 or
unfurnished
television sets, of column 5) OR
column 7 minus
actual hire
radio sets,
column 8 as may
refrigerators, charges payable
be applicable)
other household
appliances and
air-conditioning
plant or
equipment) OR
hire charges, if
hired from a third
party

0.00

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0.00

ANNEXURE
(Contd.)

Whether any
Remuneration paid by
Value of free or
conveyance has been employer for domestic concessional passages
provided by the
and / or personal
on home leave and
employer free or at a services provided to the other travelling to the
concessional rate or
employee (give details) extent chargeable to tax
where the employee is
[See rule 3(g)]
(give details) [See rule
allowed the use of one
2B read with section
or more motor cars
10(5)(ii)]
owned or hired by the
employer, estimated
value of perquisite (give
details) [See rule 3(c)]

10

11

12

Estimated value of any

other benefit or amenity
provided by the
employer, free of cost or
at concessional rate not
included in the
preceding columns (give
details), e.g.' supply of
gas, electricity or water
for household
consumption, free
educational facilities,
transport for family, etc.
[See rules 3(d), 3(e) and
3(f)]
13

Employer's contribution Interest credited to the Total of columns 9 to 15

to recognised provident assessee's account in
carried to column 8 of
fund in excess of 10%
recognised provident
Form No. 12B
of the employee's salary fund in excess of the
[See Schedule IV - Part rate fixed by the Central
A]
Government [See
Schedule IV - Part A]

14

15

16

0.00

Signature of the employee

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