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FORM 16 [See rule 31(1)(a)] PART A Certificate under section 203 of the Income-tax Act, 1961 for Tax

deducted at source on Salary Name and designation of the Employee Name and address of the Employer

PAN of the Deductor

TAN of the Deductor Assessment Year

PAN of the Employee Period From To

Address: City: Pincode: Summary of tax deducted at source Receipt Numbers of original statements of TDS under sub-section (3) of section 200 NA NA NA NA

Quarter

Amount of tax deducted in respect of the employee

Amount of tax deposited/remitted in respect of the employee

Quarter Quarter Quarter Quarter Total

1 2 3 4

NIL

NIL

PART B (Refer Note 1) Details of Salary Paid and any other income and tax deducted Rs. 1. Gross Salary
(a) Salary as per provisions contained in sec. 17(1) (b) Value of perquisites u/s 17(2) (as per Form No. 12BB, wherever applicable) (c) Profits in lieu of salary under section 17(3)(as per Form No. 12BB, wherever applicable (d) Total

Rs.

Rs.

200,640

2. Less: Allowance to the extent exempt U/s 10 Allowance Rs. House Rent Allowance Conveyance Allowance Medical Allowance

3. Balance (1-2) 4. Deductions : (a) Entertainment allowance (b) Tax on employment 5. Aggregate of 4(a) and (b) 6. Income chargebale under the head 'Salaries' (3-5) 7. Add: Any other income reported by the employee Income Rs.

8. Gross Total income (6+7)

..2

:: 2 :: 9. Deductions under Chapter VI A (A) sections 80C, 80CCC and 80CCD (a) Section 80 C (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (b) section 80 CCC (c) section 80 CCD Note: 1. Aggregate amount deductible under section 80 C shall not exceed one lakh rupees. 2. Aggregate amount deductible under the three sections, i.e. 80C,80CCC,80CCD shall not exceed one lakh rupees.

Gross Amount

Deductible Amount -

Gross (B) other sections (e.g. 80E,80G etc.) under Chapter VI-A Amount (i) section (ii) section (iii) section (iv) section (v) section 10. Aggregate of deductible amount under Chapter VI A

Qualifying Amount Deductible Amount

11. Total Income (8-10) 12. Tax on total income 13. Education cess @ 3% (on tax computed at S.No. 12) 14. Tax Payable (12+13) 15. Less: Relief under section 89 (attach details) 16. Tax Payable (14-15)

I, C.Balaji , son of Mr Chandran working in the capacity of Director do hereby certify that a sum of Rs. Nil has been deducted and deposited to the credit of the Central Government. I further certify that the information given above is true, complete and correct and is based on the books of account, documents, TDS statements, TDS deposited and other available records. Place Date Designation: Signature of person responsible for deduction of tax DIRECTOR Full Name:

ANNEXURE - B
DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN

(The Employer to provide payment wise details of tax deducted and deposited with respect to the employee) Tax Deposited in Challan identification number (CIN) S.No. respect of the Date on which tax deposited BSR Code of tbe Bank Branch Challan Serial Number employee (Rs.) (dd/mm/yyyy)

Total

ANNEXURE - A DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN (The Employer to provide payment wise details of tax deducted and deposited with respect to the Employee) S.No. Tax Deposited in respect of the employee (Rs.) Book identification number (BIN) DDO Sequence
Receipt numbers of Form No.24 G

Number in the Book Adjustment Mini Statement

Date on which tax deposited (dd/mm/yyyy)

Total

FORM 16 [See rule 31(1)(a)] PART A Certificate under section 203 of the Income-tax Act, 1961 for Tax deducted at source on Salary Name and designation of the Employee Name and address of the Employer Hood Technologies Pvt Ltd. Anand Rajasekaran Flat No :AP 391, 17 th Street Software Engineer Thiruvalluvar Kudiirupu Anna Nagar (W) Chennai - 60040 PAN of the Deductor TAN of the Deductor PAN of the Employee CHEH04763D AHSPA0025A Period Assessment Year Address: From To 20102011 1/4/2010 31/3/2011 City: Pincode: Amount Summary of tax of tax deducted at source deducted Receipt Numbers of original statements of TDS under in Quarter Amount of tax deposited/remitted in respect of the employee sub-section (3) of section 200 respect of the employe Quarter 1 e Quarter 2 Quarter 3 Quarter 4 Total PART B (Refer Note 1) Details of Salary Paid and any other income and tax deducted Rs. Rs. Rs. 1. Gross Salary
(a) Salary as per provisions contained in sec. 17(1) (b) Value of perquisites u/s 17(2) (as per Form No. 12BB, wherever applicable) (c) Profits in lieu of salary under section 17(3)(as per Form No. 12BB, wherever applicable (d) Total

AABCH8265J CIT (TDS)

200,640 -

2. Less: Allowance to the extent exempt U/s 10 Allowance Rs.

3. Balance (1-2) 4. Deductions : (a) Entertainment allowance (b) Tax on employment 5. Aggregate of 4(a) and (b) 6. Income chargebale under the head 'Salaries' (3-5) 7. Add: Any other income reported by the employee Income Rs. -

8. Gross Total income (6+7) ..2

:: 2 :: 9. Deductions under Chapter VI A (A) sections 80C, 80CCC and 80CCD (a) Section 80 C (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) Infra Bonds (b) section 80 CCC (c) section 80 CCD
Note: 1. Aggregate amount deductible under section 80 C shall not exceed one lakh rupees. 2. Aggregate amount deductible under the three sections, i.e. 80C,80CCC,80CCD shall not exceed one lakh rupees.

Gross Amount

Deductible Amount -

G Qualifying Amount (B) other sections (e.g. 80E,80G etc.) under Chapter VI-A ross Amount (i) section (ii) section

Deductible Amount

(iii) section (iv) section (v) section 10. Aggregate of deductible amount under Chapter VI A

#NAME? #NAME? #NAME?

11. 12. 13. 14. 15. 16.

#NAME? Verification I, ------------------------, son / daughter of -------------------- working in the capacity of ---------------------- (designation) do hereby certify that a sum of Rs.------------ [Rs. ----------------------------------- (in Words) has been deducted and deposited to the credit of the Central Government. I further certify that the information given above is true, complete and correct and is based on the books of account, documents, TDS statements, TDS deposited and other available records. Place Date 30/06/2011 Signature of person responsible for deduction of tax Full Name: C.BALAJI CHENNAI

Total Income (8-10) Tax on total income Education cess @ 3% (on tax computed at S.No. 12) Tax Payable (12+13) Less: Relief under section 89 (attach details) Tax Payable (14-15)

Designation: DIRECTOR

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