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

 

S.No

Nature of perquisite

 

Value of

Amount,
if any

Amount of

 

 

(see
rule 3)

 

perquisite as per

recovered
from

perquisite

 

 

 

 

 

rules

the employee

chargeable
to tax

 

 

 

 

 

(Rs.)

(Rs.)

Col(3)
– Col(4)

 

 

 

 

 

 

 

(Rs.)

(1)

 

(2)

 

 

(3)

(4)

(5)

1

Accommodation

 

 

 

 

 

2

Cars/Other automotive

 

 

 

 

3

Sweeper, gardener,

 

 

 

 

 

watchman or personal

 

 

 

 

 

attendant

 

 

 

 

 

4

Gas, electricity, water

 

 

 

 

5

Interest

free or

concessional

 

 

 

 

loans

 

 

 

 

 

 

6

Holiday expenses

 

 

 

 

7

Free or concessional
travel

 

 

 

 

8

Free meals

 

 

 

 

 

9

Free Education

 

 

 

 

 

10

Gifts, vouchers etc.

 

 

 

 

11

Credit card expenses

 

 

 

 

12

Club expenses

 

 

 

 

 

13

Use  of  movable  assets 
by

 

 

 

 

employees

 

 

 

 

 

14

Transfer

of

assets

to

 

 

 

 

employees

 

 

 

 

 

15

Value

of

any

other

 

 

 

 

benefit/amenity/service/privil

 

 

 

 

ege

 

 

 

 

 

 

16

Stock  options 
(non-qualified

 

 

 

 

options)

 

 

 

 

 

 

17

Other benefits or
amenities

 

 

 

18

Total value of
perquisites

 

 

 

19

Total value of
Profits in lieu

 

 

 

 

of salary as per 17(3)

 

 

 

 

 

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

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