Format of Form No. 12BA (Part 6 of Circular 17/2014)

ANNEXURE-II

FORM
NO.12BA {See rule 26A(2)(b)}

Statement
showing particulars of perquisites, other fringe benefits or amenities and
profits in lieu of salary with value thereof

1)     
Name
and address of employer :

2)     
TAN

3)   
TDS
Assessment Range of the employer :

4)     
Name,
designation and PAN of employee :

5)     
Is the employee a director or a person
with : substantial interest in the company

(where
the employer is a company)

6)      Income
under the head “Salaries” of the employee : (other than from
perquisites)

7)     
Financial
Year :

8)     
Valuation
of Perquisites

9. 
Details of tax, –

(a) Tax deducted
from salary of the employee u/s 192(1)                  ………

(b) Tax paid by employer on
behalf of the employee u/s 192(1A)   ………

(c) Total tax
paid                                                                                ………

(d) Date of payment
into Government treasury                                 ………

DECLARATION BY EMPLOYER

I ………………. s/o ………………….  working as ……………………………(designation)

do hereby declare on behalf of ……………..….. (name of
the employer) that the information given above is based on the books of
account, documents and other relevant records or information available with us
and the details of value of each such perquisite are in accordance with section
17 and rules framed thereunder and that such information is true and correct.

Signature of the person responsible

for deduction of tax

Place…

Date…                                                                              Full
Name ……………………

Designation…………………………

 Download Circular No. 17/2014