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[See rule 26A]

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

Permanent Account No. ____________________________

Residential status _________________________________

S. No Name and address of TAN of the employer(s) Permanent Account

employer(s) as allotted by the ITO Number of the

1 2 3 4

Signature of the employee

† With effect from 1-4-1991, section 80C has been replaced by section 88.


I,______________________________________________________do hereby declare that what is stated above is true to the best of my kn
Verified today, the_____________________day of______________________

[See column 8 of Form No. 12B]

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

Name and address of the employee ___________________________________

Permanent Account No. ______________________________

Name of the TAN/PAN of the employer Value of rent-free accommodation or value of any concession in rent for the accommodation provided by the e
employee Where accommodation is furnished
Where Value as if
accommodation is accommodation is
unfurnished unfurnished
1 2 3 4

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

1 10 11 12
M NO. 12B
rule 26A]

tion 192(2) for the year ending 31st March, _______

Period of employment Particulars of salary as defined in section 17, paid or due to be paid to the employee during the
Total amount of salary excluding Total amount of house rent Value of perquisites and
amounts required to be shown in allowance, conveyance amount of accretion to
columns 7 and 8 allowance and other employee's provident fund
allowances to the extent account (give details in the
chargeable to tax[See Annexure)
section 10(13A) read with
rule 2A and section 10(14)]

5 6 7 8

Signature of the employee


by declare that what is stated above is true to the best of my knowledge and belief.

Signature of the employee ____________________

olumn 8 of Form No. 12B]

of accretion to employee's provident fund account

Period : Year ending 31st March, _______________

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


Estimated value of any other benefit or Employer's contribution to Interest credited to the Total of columns 9 to 15
amenity provided by the employer, free of recognised provident fund in excess assessee's account in carried to column 8 of Form
cost or at concessional rate not included in of 10% of the employee's salary [See recognised provident fund No. 12B
the preceding columns (give details), e.g., Schedule IV - Part A] in excess of the rate fixed
supply of gas, electricity or water for by the Central Government
household consumption, free educational [See Schedule IV - Part A]
facilities, transport for family, etc.[See rules
3(d), 3(e) and 3(f)]

13 14 15 16
Total of columns 6, 7, and 8 Amount deducted in Total amount of Remarks
respect of life tax deducted
insurance premium, during the year
provident fund (enclose
contribution, etc., certificate issued
to which sec. 80C † under section 203)
applies (Give

9 10 11 12

Value of perquisite (column

3 minus column 8 or
column 7 minus column 8
as may be applicable)