ANSAL UNIVERSITY

FORM No.12BB (See rule 26C)

Saving & Investment Declaration form for claculation of Income Tax for the Financial Year 2019-20 (AY 2020-21) to be submitted to
Finance & Accounts Department by 4th May 2019

1. Name of the employee: SABIR ALI

2. Employee Code AU0327
3. Contact Number 8800509295
4. Permanent Account Number of the employee: BCXPA3838G
5. Financial year: 2019-20
Details of claims and evidence thereof
Sl No. Nature of claim Amount (Rs.) Evidence / particulars
(1) (2) (3) (4)
1 House Rent Allowance:
(i) Rent paid to the landlord 145,200 Rent slips
(ii) Name of the landlord RAMESHWARI DEVI
(iii) Address of the landlord GS-6, Malibu Town,
sector-47, Gurugram-
122018
(iv) Permanent Account No. of the landlord BJRPD3674C
Note: Permanent Account Number shall be furnished if the
aggregate rent paid during the year exceeds one lakh rupees
Err:522
2 Leave travel concessions or assistance
3 Deduction of interest on borrowing:
(i) Interest payable/paid to the lender
(ii) Name of the lender
(iii) Address of the lender
(iv) Permanent Account Number of the lender
(a)   Financial Institutions(if available)
(b)   Employer(if available)
(c)    Others
4 Income from Other Sources
(i) NSC / Bank Interest
(ii) Honorarium Received
(iii) Any other Income (Specify)
(a)  
(b)  
5 Deduction under Chapter VI-A
(A) Section 80C,80CCC and 80CCD
(a) Life Insurance Premium 7,057 RECEIPTS
(b) ULIP
(c) GPF/PPF
(d) Mutual Fund (Tax Saving)
(e) Infrastructure Bond
(f)
Tuition Fee (Max 2 Childrens, for Full Time Education only)

(g) Principal re-payment of Housing Loan 88,864

(h) Sukanya Samridhi Yojana (SSY)
(i) Pension Fund - 80CCC
(j) NPS Contribution by Employee-80CCD (1)
Total Upto Rs.1,50,000/-
(k) u/s 80CCD (1B) Individual Contribution by an employee upto
Rs.50,000/-
6 (a) u/s 80D - Medical Insurance
(b) u/s 80DD - Medical Expenditure of rehabilatation of handicap

(c) u/s 80DD - Medical Expenditure of specified diseases under

rule 11DD
(d) u/s 80E Interest paid only on Loan taken for higher education

(e) u/s 80G / 80GGC

Other Admissible deduction
Verification
I,…………………..,son/daughter of……………………….. do hereby certify that the information given above is complete and
correct.
Place……………………………………………...
Date…………………………………………….... (Signature of the employee)
Designation ……………………………….…. Full Name SABIR ALI