FORM NO.

12BB
(See rule 26C)
Statement showing particulars of claims by an employee for deduction of tax under section 192
1. Name and address of the employee: Shyamsundar Maruti Pednekar, 704, A Bldg, 7th floor, Arihant city,
Kalyan Bhiwandi Road, Temghar, Bhiwandi, PIN-421302
2. Permanent Account Number of the employee: AWVPP6095P
3. Financial year 2017-18
Details of claims and evidence thereof
Sl No. Nature of claim Amount (Rs.) Evidence / particulars

(1) (2) (3) (4)

1 House Rent Allowance:
(i) Rent paid to the landlord Rs.
(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

3 Deduction of interest on borrowing:
(i) Interest payable/paid to the lender Rs. 94,565
(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 80C
(i) Section 80C
(a) Premium for Life insurance Rs.
(b) NSC / NSS / National Pension Scheme Rs.
(c )Public Provident Fund Rs.
(d) Repayment of Housing Loan (principal) Rs. 56,250
(e) Equity Linked Savings Scheme Rs.
(f) Fixed Deposit with scheduled bank (5 years) Rs.
(g) Tuition fee for Childrens' education Rs.
(h) ……………………………………… Rs.
(I) ……………………………………… Rs. -
(ii) Section 80CCC Rs.
(iii) Section 80CCD Rs.
(List of investments / payments eligible for above
deductions are attached herewith for ready reference)
(B) Other sections (e.g. 80D, 80E, 80G, 80TTA, etc.) under Chapter VI-A.
(i) section 80 D
Mediclaim - self, spouse, children (max Rs.25k) Rs. 45286.41
Mediclaim - Dependent parents of age <60 years old (max Rs.25k) Rs.
conditions:
Mediclaim - Dependent parents of age >60 years old (max Rs.50k) Rs. Property value
(ii) section 80G - Donations to notified funds Rs. Home loan sha
(iii) section 80EE - Home loan interest for first time home buyers (Max Rs. 50K) to be sanction

(iv) section……………….
(v) section……………….
Verification
I,Shyamsundar Maruti Pednekar,son/daughter of Maruti Shankar Pednekar do hereby certify that the information given above is
complete and correct.
Place : Thane, Bhiwandi……………………………………………...
Date 11.07.2018…………………………………………….... (Signature of the employee)
Designation Sr. Draughtsman……………………………….…. SHYAMSUNDAR MARUTI PEDNEKAR
Note:
Supporting documents to be attached
1 House Rent Allowance : Annexure - I along with Self attested copies of Rent Receipts
and Rent agreement
2 Deduction of Interest on borrowing : Self attested copy of Interest Certificate from Lending bank
3 Deductions under Chapter VIA : Self attested copies Investment / Payment proof
4 Medical Re-imbursement : Annexure - II along with original bills
 ANNEXURE - I
CLAIM FOR HRA EXEMPTION U/S 10 (13A)
F.Y. 2017-18
Name of the employee :

Name of the Landlord

If the annual rent
IT PAN of the Landlord exceeds Rs. 1 Lac
Address of the property

Rent paid Month Amount (Rs.)

Apr-17
May-17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Mar-18
Total -

S I G N A T U R E

Note: Self attested copies of Rent Receipt and Rent agreement to be attached
 ANNEXURE - II
MEDICAL RE-IMBURSEMENT
F.Y. 2017-18
Name of the employee : Mr. Shyamsundar Maruti Pednekar
April 2017 to March 2018
Incurred for (Please mention the relationship): Anvit Shyamsundar Pednekar (Son)
Discription Bill No. Bill date Amount (Rs.)
Saraswati Medical & Genreal Store SC41 03.04.2017 622.00
Millenium Children Clinic 154 09.09.2017 1000.00
Millenium Children Clinic 205 30.10.2017 600.00
Sagar Medical & General Store CA/7813 27.11.2017 98.83
Devendar Medical & Genreal Store 3656 10.12.2017 130.00
Saraswati Medical & Genreal Store SC3596 11.12.2017 673.00
Millenium Children Clinic 255 11.12.2017 1500.00
Dr. Vig Medicaments 24034-P 22.12.2017 117.68
Ma Ambica Chemist 9958 23.12.2017 135.00
Ma Ambica Chemist 10141 26.12.2017 180.00
Little Tooth 456 07.01.2018 9000.00
Akshay Medical & General Stores CA/8385 26.01.2018 42.26
Parekh Medical & General Stores CA/6480 26.01.2018 264.97
Total 14363.74

I hereby declare that the above statement is true to the best of my knowledge and the person
on behalf of whom medical expenses were incurred is wholly dependent on me

S I G N A T U R E

Note: 1. Original Bills / Receipts to be attached

2. Expenses relating to cosmetics, health drinks etc are not allowed.
 ANNEXURE - II
MEDICAL RE-IMBURSEMENT
F.Y. 2017-18
Name of the employee : Mr. Shyamsundar Maruti Pednekar
April 2017 to March 2018
Incurred for (Please mention the relationship): Aruna Shyamsundar Pednekar (Wife)
Discription Bill No. Bill date Amount (Rs.)
Vijay Medical & Genreal Stores CA/16 01.04.2017 214.19
Life Care Pharmacy & General Stores CA-245 04.04.2017 1220.50
P. D. Hinduja Hospital ORE171160/17 05.04.2017 2400.00
P. D. Hinduja Hospital ORE171031/17 05.04.2017 1500.00
Suburban Diagostics 1709600859 06.04.2017 6950.00
P. D. Hinduja Hospital ORE177647/17 08.04.2017 2600.00
Anand Medical & General Stores CA-427 08.04.2017 834.44
Sagar Medical & General Stores CA/1263 12.05.2017 117.04
Ganesh Diagnostic Centre 617 24.05.2017 400.00
Suburban Diagostics 1714501024 25.05.2017 7160.00
P. D. Hinduja Hospital ORE269791/17 02.06.2017 1500.00
P. D. Hinduja Hospital ORE269809/17 02.06.2017 1500.00
P. D. Hinduja Hospital ORE270362/17 02.06.2017 1500.00
Anand Medical & General Stores 3125 02.06.2017 1920.00
Life Care Pharmacy & General Stores CA-4887 10.06.2017 276.50
Sagar Medical & General Stores CA/6038 27.09.2017 230.00
Sahyadri Medical & General Stores 115961 11.12.2017 150.00
Suburban Diagostics 1735301714 19.12.2017 200.00
Mid Town Diagnostics 809 13.03.2018 250.00
Total 30922.67

I hereby declare that the above statement is true to the best of my knowledge and the person on
behalf of whom medical expenses were incurred is wholly dependent on me

S I G N A T U R E

Note: 1. Original Bills / Receipts to be attached

2. Expenses relating to cosmetics, health drinks etc are not allowed.