Form for sending particulars of income u/s 192(2B) for the year ending 31st March 2017

1. Name and address of the employee2. Employee No3. Permanent Account Number 4. Residential status- Resident Indian
5. Particulars of income under the head salaries" (drawn from employer other than DVC) Rs.
received during the financial year.
6. Income/ Loss from house property: [(+) for income () for loss]
Rs. (-)
(Bank / Fin Institutions Statement on accrued interest needs to be submitted)
7. PERQUISITE VALUE
(i) Perquisite value for Accommodation provided by Previous Employer.
Rs.
(Applicable in case of deputationist or employees joining from other organization)
(ii) Value of Furniture & Fixtures provided by previous employer
Rs.
(Applicable in case of deputationist or employees joining from other organization)
(iii) Perquisite value for DVCs Accommodation (in case of transferee)
Rs.
(iv) Value of Furniture & Fixtures provided by DVC
Rs.
(v) Other non monitory facilities provided by DVC/ other employer
Rs.
8. Aggregate of item No 5 TO 7:
Rs.
9. INCOME FROM OTHER SOURCES
(a) Interest Income (Saving Bank A/c) please specifies the exact amount
(b) Any other income (FD Interest etc)

Rs.
Rs.

10. P Tax recovered (if any, by Previous employer)

Rs.
11. For exemption U/S- 10 (13A) Rent Paid @ Rs.
from ..201 to .201
(House Rent Receipt & PAN NO of the Landlord required for claiming deduction)
12. Rebate U/S- 80 Ci. HB Principal RepaymentRs.
ii. LIC Premium Rs.
iii PPF Contribution
Rs.
iv. PF recovered by previous employer
Rs.
13. Rebates under Section -80DD( for Handicapped dependent )Rs.
14. Education Loan Interest -80E
Rs.
15. Mediclaim Insurance Premium Rs.
16.
17. TDS deducted by previous employer (TAN NO)
Rs.

Verification
I,
do hereby declare that what is stated above is true to the best of my
knowledge and belief. I also declare that, I have understood the implications and conditions for claiming the rebate
under section 80C for repayment of Principle amount of HB Loan and also the conditions applicable for claiming
rebate for accrued interest on HB Loan under Section 24(b) . I also fulfill the conditions specified for claiming
rebate U/s-10(13A) for the Assessment Year-2017-18 and will be held personally responsible if any of the material
facts , as claimed above, is found to be false, incorrect or even partially correct in future and culminate in as an
undue advantage in determining my Tax Liability for the Assessment Year 2017-18. In the event of drawing salary
from more than one employer during the FY-2016-17, I hereby authorize the current DDO DVC to calculate my tax after
taking into account the pay & allowance drawn from my previous employer.
Verified today, the day of 2016 .

Place- MTPS.

Signature of the employee