Form No 12B – Fill Out and Use This PDF

Particulars of salary as defined in section 17, paid or

due to be paid to the employee during the year

Total amount of

Amount

house rent

Value of

deducted in

Total amount

Total amount

allowance,

perquisites and

respect of life

of tax

of salary

conveyance

amount of

insurance

deducted

TAN of the

Permanent

excluding

allowance and

Name and

accretion to

Total of

premium,

during the

S.

employer(s)

Account

Period of

amounts

other allowances

address of

employee's

columns 6,

provident fund

year

Remarks

No

as allotted by

Number of the

employment

required to

to the extent

employer(s)

provident fund

7, and 8

contribution,

(enclose

the ITO

employer(s)

be shown in

chargeable to

account (give

etc., to which

certificate

columns 7

tax[See section

details in the

sec. 80C †

issued under

and 8

10(13A) read with

Annexure)

applies (Give

section 203)

rule 2A and

details)

section 10(14)]

1

2

3

4

5

6

7

8

9

10

11

12

Name and address of the employee

Permanent Account No.

Period : Year ending 31st March,

Name of the

TAN/PAN of the

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)

employee

employer

and 3(b)]

Where accommodation is furnished

Where

Value as if

Cost of furniture (including

Perquisite value

Total of columns

Rent, if any,

Value of perquisite

accommodation is

accommodation is

television sets, radio sets,

of furniture (10%

4 and 6

paid by the

(column 3 minus

unfurnished

unfurnished

refrigerators, other household

of column 5) OR

employee

column 8 or column

appliances and air- conditioning

actual hire

7 minus column 8 as

plant or equipment) OR hire

charges payable

may be applicable)

charges, if hired from a third party

1

2

3

4

5

6

7

8

9

ANNEXURE

(Contd.)

Estimated value of any

Whether any conveyance

other benefit or amenity

Value of free or

provided by the employer,

has been provided by the

Interest credited to

Remuneration

concessional

free of cost or at

employer free or at a

the assessee's

paid by employer

passages on

concessional rate not

concessional rate or

Employer's contribution to

account in

for domestic

home leave and

included in the preceding

where the employee is

recognised provident fund in

recognised provident

Total of columns 9 to

Name of the

and/or personal

other travelling to

columns (give details),

allowed the use of one or

excess of 10% of the

fund in excess of the

15 carried to column 8

employee

services provided

the extent

e.g., supply of gas,

more motor cars owned

employee's salary [See

rate fixed by the

of Form No. 12B

to the employee

chargeable to tax

electricity or water for

or hired by the employer,

Schedule IV - Part A]

Central Government

(give details) [See

(give details) [See

household consumption,

estimated value of

[See Schedule IV -

rule 3(g)]

rule 2B read with

free educational facilities,

perquisite (give details)

Part A]

section 10(5)(ii)]

transport for family,

[See

rule 3(c)]

etc.[See rules 3(d), 3(e)

and 3(f)]

1

10

11

12

13

14

15

16

Estimated value of any

Whether any conveyance

other benefit or amenity

Value of free or

provided by the employer,

has been provided by the

Interest credited to

Remuneration

concessional

free of cost or at

employer free or at a

the assessee's

paid by employer

passages on

concessional rate not

concessional rate or

Employer's contribution to

account in

for domestic

home leave and

included in the preceding

where the employee is

recognised provident fund in

recognised provident

Total of columns 9 to

Name of the

and/or personal

other travelling to

columns (give details),

allowed the use of one or

excess of 10% of the

fund in excess of the

15 carried to column 8

employee

services provided

the extent

e.g., supply of gas,

more motor cars owned

employee's salary [See

rate fixed by the

of Form No. 12B

to the employee

chargeable to tax

electricity or water for

or hired by the employer,

Schedule IV - Part A]

Central Government

(give details) [See

(give details) [See

household consumption,

estimated value of

[See Schedule IV -

rule 3(g)]

rule 2B read with

free educational facilities,

perquisite (give details)

Part A]

section 10(5)(ii)]

transport for family,

[See

rule 3(c)]

etc.[See rules 3(d), 3(e)

and 3(f)]

1

10

11

12

13

14

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16