ANNUAL INCOME TAX STATEMENT FOR THE FINANCIAL YEAR 2012-2013 (Assessment Year 2013-2014) Name, Designation and

Official Address of the Government Servant [ in BLOCK letters] Residential Address

Sex: PAN: 1 a 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 b c d e f g 2

Male / Female TAN: Gross Salary Income (Include Pay, DA, HRA, CCA, IR, etc.) March 2012 April May June July August September October November December January February Leave Surrender Festival Allowance / Bonus / Food Allowance / Medical Allowance etc. Pay Revision Arrears Value of prequisites u/s 17(2) (as per Form No. 12BA, wherever applicable) Profits in lieu of salary u/s 17(3) (as per Form No. 12BA, wherever applicable) Total Salary income(a+b+c+d+e+f) Deduct: The actual HRA received or House Rent actually paid in excess of 10% of the pay plus DA or 50% of pay plus DA whichever is the least in case residing in a rented building u/s 10 (13A) 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 Station : Rs. Rs.

Rs.

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Balance (1-2) Deduct Entertainment Allowance [see 16 (ii)] Professional Tax paid in 2012-'13 Any other allowance exempted u/s 10 Total 4(a) + 4(b) + 4(c) Income Chargeable under the head Salaries (3-4) Add income from other sources Add income from house property Deduct interest/accured interest on HBA (maximun admissible is Rs 30,000/- (if the property is acquired or constructed on or after 01.04.99 and such acquisition or construction is completed within three years from the end of the financial year in which capital is borrowed, deductible amount is 1.50 Lakh) Gross Total income(5+6+7-8) Individual & HUF Below age of 65 years Income tax up to 2,00,000 Rs 2,00,001 - 5,00,000 Rs 5,00,001 - 10,00,000 Above Rs 10,00,001 Tax Rates Nil 10% 20% 30% Women below age of 65 years Income tax up to 2,00,000 Rs 2,00,001 - 5,00,000 Rs 5,00,001 - 10,00,000 Above Rs 10,00,001 Tax Rates Nil 10% 20% 30%

Rates of Income Tax

Education Cess: An addl. surcharge called E.C. @ 2% on the amount of income tax & surcharge (if any) in all cases shall be levied Secondary & Higher : An additional surcharge, called the Secondary & Higher E. C. on income tax at the rate of 1% of income tax Rs. Rs. B/F 1 Deductions under Chapter VI A: 0 A Under Section 80 C a GPF/PPF Contributions b LIC Premium (himself/spouse/children) not exeeding 20% of total Sum assured c GIS/FBS/SLI/PLI premium d Contribution towards LIC's Dhanaraksha Mutual Fund e Any annuity or Deferred Annuity plan f Subsciption towards NSC VIII issue g Contribution to UTI's Retirement Benefit Plan h Investment in UTI's Unit Linked Insurance Plan

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Approved Mutual Fund Investments u/s 10(23D) Repayment of Housing Loan Principal towards self occupied Residential Property k Repayment of tuition fee towards any 2 children of assessee l Investment in Equity Linked Savings Scheme / Approved Infrastructure Bonds m Investment in pension Fund/Deposit of National Housing Bank under Home Loan Account Scheme n Fixed deposit on any Scheduled Bank/Housing Finance Company for not less than 5 years o Amount invested in a 5 Year Post Office Term Deposit Account p Amount invested in a Senior Citizen Savings Schekme, 2004 B U/S 80CCC - Premium paid towards IRDA approved Pension Fund C U/S 80CCD - Pension Scheme vide Notification No. F.N.5/7/2003 - ECB & PR dt. 22.12.03 D The aggregate amount of deduction u/s 80C, 80CCC & 80CCD(max. 1 Lakh) U/S 80CCF A B C D E F G H U/S 80D - Medical insurance premium (max. 15,000) U/S 80DD - Maintenance including medical treatment of Handicaped dependent U/S 80DDB - Medical treatment expense (max. 40,000) (For Senior Citizen Max. 60,000) U/S 80E - Payment of interest on loan taken for higher studies U/S 80G - Donations made to recognized funds) Rate of deduction is 50% U/S 80GG - If an assessee not in receipt of HRA incurs any expenditure on rent U/S 80 U - Disability allowance Any other allowance (specify) Aggregate of deductible amount under chapter VIA (10D+11+12A+B+C+D+E+F+G+H) Total Income (9-13) Total Income in multiples of Tens Income tax due on total income in 14 A Normal tax or tax under marginal releif (if income

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A a b

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exceeds 10 lakhs) Surcharge (on tax at computed at S.No 15) a b Education cess 2% (on Sl. No.15 & Sl. No.16) Secondary & Higher Education Cess 1% (on Sl. No.15 & Sl. No.16) Total tax payable (15+16+17(a)+17(b)) Less: releif u/s 89, if any (attach details) Tax Payable (18-19) Less (a)Tax deduction at source u/s 192(1) (b) Tax paid by employer on behalf of employee u/s 192(IA) on prequisites u/s 17 (2) Balance Tax Payable (20-21) Remarks: Signature of the Officer in case of G.Ps / Signature of the Head of Office in case of Non G.Ps Name : Designation :

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2 2 2 3 Place: Date: