FORM NO.

16 [See rule 31(1)(a)] Certificate under section 203 of the Income-tax Act, 1961 for tax deducted at source from income chargeable under the head Salaries Name and address of the Employer Name and designation of the Employee

PAN No. of the Deductor

TAN No. of the Deductor

PAN No. of the Employee Period Assessment Year

Acknowledgement Nos. of all quarterly statements of TDS under sub-section (3) of section 200 as provided by TIN Facilitation Centre or NSDL web-site Quarter Acknowledgement No.

From

To

DETAILS OF SALARY PAID AND ANY OTHER INCOME AND TAX DEDUCTED 1 Gross Salary (a) (b) Salary as per provisions contained in sec.17(1) Value of perquisites u/s 17(2) (as per Form No.12BB, wherever applicable) Rs Rs

(c) (d) 2

Profits in lieu of salary under section 17(3)(as per Form Rs No.12BB, wherever applicable) Total Rs Rs Rs Rs Rs Rs

Less: Allowance to the extent exempt u/s 10

3 4

Balance(1-2) Deductions : (a) (b) (c) Standard deduction Entertainment allowance Tax on employment Rs. Rs. Rs. Rs

5 6

Aggregate of 4(a) to (c) Income chargeable under the head 'salaries' (3-5)

Rs

Add: Any other income reported by the employee

Rs Rs Rs Rs Rs

8 9

Gross total income (6+7) Deductions under Chapter VIA Gross Amount (a) (b) (c) (d) Rs Rs Rs Rs Qualifying Amount Rs Rs Rs Rs Deductible Amount Rs Rs Rs Rs

Rs Rs Rs Rs

10 11 12 13

Aggregate of deductible amount under Chapter VIA Total Income (8-10) Tax on total income Rebate and relief under Chapter VIII I. Under section 88 (please specify) Gross Amount (a) (b) (c) (d) (e) Rs Rs Rs Rs Rs Qualifying Amount Rs Rs Rs Rs Rs Rs Rs Rs Rs Tax rebate/ relief

(f) Total [(a) Rs to (e)] II (a) (b) III Under section 88B Under section 88C

Under section 89 (attach details)

14 15 16 17

Aggregate of tax rebates and relief at 13 above [I(f) + II(a)+ II(b) + III] Tax payable (12-14) and surcharge thereon Less: Tax deducted at source Tax payable/refundable (15-16)

Rs Rs Rs Rs

I _____________________________________, son/daughter of _________________________________ working in the capacity of ________________________________________ (designation) do hereby certify that a sum of Rs. ____________________________ [Rupees ____________________________________________ _____________________________________________________________________________ (in words)] has been deducted at source and paid to the credit of the Central Government. I further certify that the information given above is true and correct based on the books of accounts, documents and other available records.

Date Place Signature of person responsible for deduction of tax Full Name Designation

13

Rebate and relief under Chapter VIII I. Under section 88 (please specify) Gross Amount (a) (b) (c) (d) (e) Rs Rs Rs Rs Rs Qualifying Amount Rs Rs Rs Rs Rs Rs Rs Rs Rs Rs Rs Rs Rs Tax rebate/ relief

(f) Total [(a) Rs to (e)] II (a) (b) III 14 15 16 17 Under section 88B Under section 88C

Under section 89 (attach details)

Aggregate of tax rebates and relief at 13 above [I(f) + II(a)+ II(b) + III] Tax payable (12-14) and surcharge thereon Less: Tax deducted at source Tax payable/refundable (15-16)

I _____________________________________, son/daughter of _________________________________ working in the capacity of ________________________________________ (designation) do hereby certify that a sum of Rs. ____________________________ [Rupees ____________________________________________ _____________________________________________________________________________ (in words)] has been deducted at source and paid to the credit of the Central Government. I further certify that the information given above is true and correct based on the books of accounts, documents and other available records. Place Date Designation Signature of person responsible for deduction of tax Full Name