FORM NO.

12BB

(See rule 26C)

Statement showing particulars of claims by an employee for deduction of tax under section 192

: AKSHAY PAGARIYA
Name and address of the employee
Permanent Account Number of the employee : CHYPP9560K
Financial year : 2017-2018

Details of claims and evidence thereof

SR.NO. Nature of Claim Amount(RS.) Evidence / particulars

1 House Rent Allowance

(i)Rent paid to the landlord 0

(ii)Name of the landlord : Rahul Aggarwal

(iii)Address of the landlord : Civitech Sampriti Noida

(iv)Permanent Account Number of the landlord :

2 Leave travel concessions or assistance

3 Deduction of interest on borrowing

(i)Interest payable/paid to the lender 0

(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 80CCD

(i) Section 80C

(a) Bank Fd 0

(b) Children Education 0

(c) E.L.S.S. 0

(d) Housing Loan Principal Repayment 0

(e) Infrastructure Bonds 0

(f) Lic 0

(g) Lic Promise 0

(h) Mutual Fund 0

(i) Nsc 0

(j) Nss 0

(k) Other Investment 0

(l) Other Promise (80c) 0

(m) Post Office Deposit 0

(n) Ppf 0

(o) Ppf Promise 0

(p) Sukanaya Samriddhi Scheme 0

(q) Ulip 0

(r) PF+VPF 67387

(ii) Section 80CCC

(a) Jeevan Suraksha 0

(iii) Section 80CCD

(B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A.

(a) Mediclaim Policy 0

(b) Mediclaim Promise 0

(c) Handicapped Dependent - 80dd 0

 (d) Higher Education Loan Repayment 0

(e) Nps - U/S 80ccd(1b) 0

(f) Rajiv Gandhi Equity Savings Scheme 0

(g) Treatment Of Sp. Diseases 80ddb 0

(h) Additional Home Loan Interest Deduction 0

(i) Self Handicap 80u 0

Verification

I,AKSHAY,son/daughter of NIRMAL KUMAR PAGARIYA do hereby certify that the information given above is complete and correct.

Place :

Date : (Signature of the employee)

Full Name : AKSHAY

Designation : APPLICATIONS ENGINEER, II
PAGARIYA