Tax Information Network of Income Tax Department Certificate No.

: SWZNRZ
Last Updated 18/01/2012

FORM NO.16A
[See rule 31(1)(b)]

Certificate under section 203 of the Income-tax Act, 1961 for Tax deducted at source

Name and address of the Deductor Name and address of the Deductee

HIREN MAHESH JOSHI TRIVEDI KINJAL RAJESH

RAMAGULAB APTS, F 14 MANORATH TENAMENT OPP SAI MANDIR,
TEJPAL SCHEME MAIN ROAD VILEPARLE EAST, TP 13 ROAD CHHANI JAKAT NAKA,
MUMBAI MAHARASHTRA 400057 VADODARA GUJARAT 390002

PAN of the Deductor TAN of the Deductor PAN of the Deductee

AHZPJ8905D MUMH12809G ANGPT9453K

CIT (TDS) Assessment Year Period

The Commissioner of Income Tax (TDS) From To

Room No. 900A 9th Floor, 2012-13
K.G. Mittal Ayurvedic Hospital Building Charni Road, 01/10/2011 31/12/2011
Mumbai 400002

Summary of Payment

Amount paid/credited Nature of payment Date of payment/credit Status of Booking

( ) (dd/mm/yyyy)

165.00 194H - Commission or Brokerage 01/10/2011 MATCHED

150.00 194H - Commission or Brokerage 22/10/2011 MATCHED

Summary of tax deducted at source in respect of deductee

Quarter Receipt Numbers of original quarterly Amount of tax deducted in Amount of tax deposited/
statements of TDS under sub-section (3) of respect of the deductee remitted in
section 200 ( ) respect of the deductee
( )

Q3 ECQXBFOC 32.00 32.00

I. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN(The deductor to
provide payment wise details of tax deducted and deposited with respect to the deductee)

S. No. Tax Deposited in Book Identification number (BIN)

respect of the
deductee Receipt numbers of Form DDO sequence Number Date on which tax Status of Booking
( ) No. 24G in the Book Adjustment deposited (dd/mm/yyyy)
Mini Statement

Total ( ) N.A. N.A.

II. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN (The deductor to
provide payment wise details of tax deducted and deposited with respect to the deductee

S. No. Tax Deposited in Challan Identification number (CIN)

respect of the
deductee BSR Code of the Bank Date on which tax Challan Serial Status of Booking
( ) Branch deposited Number
(dd/mm/yyyy)

1 17.00 0510308 05/11/2011 50509 MATCHED

2 15.00 0510308 05/11/2011 50509 MATCHED

Total ( ) 32.00

Verification

I, HIREN JOSHI, son/daughter of MAHESH working in the capacity of PROPRIETOR (designation) do hereby certify that a sum of ( ) 32.00
[Rupees Thirty Two only] has been deducted and a sum of ( ) 32.00 [Rupees Thirty Two only] has been deposited to the credit of the Central
Government. I further certify that the information given above is true, complete and correct and is based on the books of account, documents, TDS
statements, TDS deposited and other available records.

Place MUMBAI

Date 20/01/2012 Signature of person responsible for deduction of tax

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Tax Information Network of Income Tax Department Certificate No.: SWZNRZ
TAN of the Deductor MUMH12809G PAN of the Deductee ANGPT9453K Assessment Year 2012-13 Quarter Q3 Last Updated 18/01/2012
Notes:
1. Government deductors to fill information in item I if tax is paid without production of an Income-tax challan and in item II if tax is paid accompanied by an
income-tax challan.
2. Non-Government deductors to fill information in item II.
3. In item I and II, in the column for TDS, give total amount for TDS, Surcharge (if applicable) and education cess.
4. The deductor shall furnish the address of the Commissioner of Income-tax (TDS) having jurisdiction as regards TDS statements of the assessee.
5. This Form shall be applicable only in respect of tax deducted on or after 1st day of April, 2010.

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