FORM NO.

16
[See rule 31(1) (a)]

PART A
Certificate under section 203 of the Income ta! Act" 1#61 for ta! deducted at source on sa$ar% Certificate No. &ast u'dated on Name and address of the (m'$o%er Name and address of the (m'$o%ee

PAN of the )eductor

TAN of the )eductor

PAN of the (m'$o%ee

(m'$o%ee Reference No. 'ro*ided +% the (m'$o%er ,If a*ai$a+$e-

Assessment /ear CIT ,T).Address . City.Pin code..,

Pe rio d

0ith the (m'$o%er

Fr om

To

.ummar% of amount 'aid1credited and ta! deducted at source thereon in res'ect of the em'$o%ee 2uarter,sRece Num+ers i't of 4uarter$% statements
under su+ section

ori3in a$ o T f ).
, 3 of

Amou nt 'aid1credited

Amount of ta! deducted , Rs. -

Amount of ta! de'osited1 remitted

,Rs. section 200

Tota$ ,Rs.-

I. )(TAI&. OF TA5 )()6CT() AN) )(PO.IT() IN T7( C(NTRA& 8O9(RNM(NT ACCO6NT T7RO687 :OO; A)<6.TM(NT ,The deductor to 'ro*ide 'a%ment 0ise detai$s of ta! deducted and de'osited 0ith res'ect to the deductee.$. No. Ta! )e'osited in res'ect of the deductee , Rs. :oo= Identification Num+er ,:INRecei't num+ers of ))O seria$ num+er in Form No. )ate of transfer .tatus of matchin3

2>8

*oucher

Form No. 2>8 ,dd1mm1%%%%-

0ith Form No.2>8

Tota$ , Rs. II. )(TAI&. OF TA5 )()6CT() AN) )(PO.IT() IN T7( C(NTRA& 8O9(RNM(NT ACCO6NT T7RO687 C7A&&AN ,The deductor to 'ro*ide 'a%ment 0ise detai$s of ta! deducted and de'osited 0ith res'ect to the deductee.$. No. Ta! )e'osited in res'ect Cha$$an Identification Num+er ,CINof the deductee

:.R Code of the :an= , Rs. :ranch

)ate on 0hich ta! de'osited ,dd1mm1%%%%-

Cha$$an .eria$ Num+er

.tatus of matchin3 0ith O&TA.

Tota$ , Rs. 9erificat ion I"?????.." son1dau3hter of ????.0or=in3 in the ca'acit% of ??. ,desi3nation- do here+% certif% that a sum of Rs. ????.. @Rs. ????.,in 0ords-A has +een deducted and de'osited to the credit of the Centra$ 8o*ernment. I further certif% that the information 3i*en a+o*e is true" com'$ete and correct and is +ased on the +oo=s of account" documents" T). statements" T). de'osited and other a*ai$a+$e records. P$ace )ate )esi3nationB NotesB Fu$$ NameB ,.i3nature of 'erson res'onsi+$e for deduction of ta!-

1. &. 3. -. 2. /.

Government deductors to fill information in item I if ta is !aid "it#out !roduction of an income$ta c#allan and in item II if ta is !aid accom!anied %y an income$ta c#allan. 'on$Government deductors to fill information in item II. (#e deductor s#all furnis# t#e address of t#e Commissioner of )ncome$ta ((*S) #avin+ ,urisdiction as re+ards (*S statements of t#e assessee. )f an assessee is em!loyed under one em!loyer only durin+ t#e year, certificate in .orm 'o. 1/ issued for t#e 0uarter endin+ on 31 st 1arc# of t#e financial year s#all contain t#e details of ta deducted and de!osited for all t#e 0uarters of t#e financial year. )f an assessee is em!loyed under more t#an one em!loyer durin+ t#e year, eac# of t#e em!loyers s#all issue Part A of t#e certificate in .orm 'o. 1/ !ertainin+ to t#e !eriod for "#ic# suc# assessee "as em!loyed "it# eac# of t#e em!loyers. Part 3 (Anne ure) of t#e certificate in .orm 'o.1/ may %e issued %y eac# of t#e em!loyers or t#e last em!loyer at t#e o!tion of t#e assessee. )n items I and II" in column for ta de!osited in res!ect of deductee, furnis# total amount of (*S and education cess.

PART : ,Anne!ure)etai$s of .a$ar% 'aid and an% other income and ta! deducted 1 Gross Salary (a Salary as !er !rovisions contained in ) sec.15(1) (% ) (c ) (d ) & 4s . 4s.

6alue of !er0uisites u7s 15(&) (as !er .orm 'o.1&3A, "#erever a!!lica%le) Profits in lieu of salary under section 15(3)(as !er .orm 'o.1&3A, "#erever a!!lica%le) (otal 8ess9 Allo"ance to t#e e tent e em!t u7s 1: Allo"ance 4s.

4s.

4s.

4s.

4s.

4s.

3 -

3alance(1$&) *eductions 9 (a ) ;ntertainment allo"ance (% ) (a on em!loyment A++re+ate of -(a) and (%) )ncome c#ar+ea%le under t#e #ead <salaries< (3$2) Add9 Any ot#er income re!orted %y t#e em!loyee )ncome 4s.

4s.

4s. 4s. 4s. 4 s .

2 / 5

4s. = Gross total income (/>5) *eductions under C#a!ter 6)$A 4 s .

(1)
(a) section =:C (i) (ii) (iii) (iv)

sections =:C, =:CCC and =:CC* Gross Amount . . . . 4s. 4s. 4s. 4s. *educti%le amount

(2) (/)
(vii)

. . 4 s .

4s.

(%) section =:CCC

4s. section =:CC*

4 s .

(3)

'ote9 1. A++re+ate amount deducti%le under sections =:C, =:CCC and =:CC*(1) s#all not e ceed one la@# ru!ees.

At#er sections (e.+. =:;, =:G, =:((A, etc.) under C#a!ter 6)$A. Gross amount (i) (ii) (iii) (iv) (v) 1 : 1 1 1 & 1 3 1 1 2 1 / section.. section.. section.. section.. section.. 4s. 4s. 4s. 4s. 4s. Bualifyin+ amount 4s. 4s. 4s. 4s. 4s. *educti%le amount 4s. 4s. 4s. 4s. 4s. 4s 4s 4s 4s. 4s. 4s 4s. 9erification I" ???????????.." son1dau3hter of ???????????????.0or=in3 in the ca'acit% of .?????????......... ,desi3nationdo here+% certif% that the information 3i*en a+o*e is true" com'$ete and correct and is +ased on the +oo=s of account" documents" T). statements" and other a*ai$a+$e records. P$ace )ate ,.i3nature of 'erson res'onsi+$e for deduction of ta!Fu$$ NameB CCCCCCCCCCCCCCCCCCCCCCCDE

A++re+ate of deducti%le amount under C#a!ter 6)$A (otal )ncome (=$ 1:) (a on total income ;ducation cess C 3D (on ta com!uted at S. 'o. 1&) (a Paya%le (1&>13) 8ess9 4elief under section =? (attac# details) (a !aya%le (1-$ 12)

)esi3nationB