RLY. PH.

No…………
Mobile No. ……………
DECLARATION OF SAVINGS FOR INCOME- TAX FOR
THE FINANCIAL YEAR 2019-20
AU: BU: PF No. : PAN:
IMPORTANT: WITHOUT PAN No SAVING FORM WILL NOT
BE ENTERTAINED

Name & Designation ………………………………….…Male/Female …..……

A) Income Exempt from Tax U/s-10 (13A)
Whether living in rented house. If so, please state Address:
Address and rent paid p.m. (rent receipts must be
Furnished) Exemption allowed only if the employee
Does not own any residential accommodation at the
place where he ordinarily resides or performs duties. Rent:Rs…………(p.m.)
B) Important Permissible deductions from G.T.I Amount Date of
Payment
1. Deduction Permissible U/s-80C (Substituted for
rebate U/s 88)

a. Life Insurance premium paid in 2017-18

(Premium up to 20% of Sum Assured)
a. Life Insurance Policy assured for Rs……… Rs…………..
b. Life Insurance Policy assured for Rs……… Rs…………..
c. Life Insurance Policy assured for Rs……… Rs…………..
d. Life Insurance Policy assured for Rs……… Rs…………..
e. Life Insurance Policy assured for Rs……… Rs…………..
TOTAL: Rs. ……………………….
b. Amount of ULIP premium paid Rs…………..
c. Amount of PPF paid with Post office and/or SBI etc. Rs…………..
(A/c. No……………………………) (Max. 1,00,000/-)

d. Refund of Principal amount of House Building Advance in

r/o Ready Built/construction of House. Construction of
which is completed before 31.03.2018 completion
Certificate is to be produced. Rs…………..
e. Amount of Post Office CTD (10 & 15 yrs) Rs…………..
f. Contribution by an individual in the name of Himself his/
her wife/husband or his child and by an HUF in the name
of any of its members, participation in any unit-linked
insurance plan of the LIC Mutual Fund specified in this
behalf viz. Dhanraksha – 1989 Plan [Sec.80C(2)(xi)read
with Sec.80C(4)(a)] Rs…………..
g. Deposits under New Jeevan Dhara-I/New Jeevan Akshaya-
I and other policies of LIC on which rebates are allowed
Under Income Tax Act.
Policy No…………… A/c. No……………
(Premium upto 20% of Sum Assured) Rs…………..
h. Subscription to any units of a Mutual Fund
notified U/s. 10(23D) or of UTI under any Plan
formulated in accordance with Equity Linked Saving
Scheme. It will be the responsibility of the employee to
ensure that the schemes notified by Govt, for I.Tax rebate Rs…………..
i. Tuition Fees whether at the time of admission or thereafter,
to any university, college, school, or other educational
institution situated in India for the purpose of full time
education of any two children of the assesses, However,
any development fees or donation or payment of similar
nature shall not be eligible for deduction. Rs…………..
j. Any other item specified under I.Tax Act such as
shares/debentures and units of notified eligible mutual
funds Rs…………..

k. Particulars of Accrued Interest of six years NSCs (VIII issue) if any as under:-

Purchased during the Amount of 6years NSC Rate of Interest

year (VIII the Issue) Interest % Accrued
2012-2013 08.16 --------------
----------------------------------------------
2013-2014 08.83 --------------
----------------------------------------------
2014-2015 09.55 --------------
----------------------------------------------
2015-2016 10.33 --------------
----------------------------------------------
2016-2017 11.17 --------------
----------------------------------------------
2017-2018 12.08 --------------
----------------------------------------------

Total=
l. Particulars of 6 years NSCs purchased during the Financial Year 2017-18
No. of NSCs Date of NSCs Amount in Rs.

Total =

m. Rs……………….
Notified Pension Scheme U/s 80CCC(max Rs.1,00,000)
Note: Aggregate amount of deductions U/s 80C, 80CCC and 80CCD is restricted to
Rs.1,00,000 vide Sec. 80CCE.

2. Mediclaim U/s 80D(Max.Rs.25,000) for self Rs…………..

and (max. Rs.30,000) for parents

3. Medical Treatment and deposits for Physically

Handicapped dependent U/s80DD(Rs.75,000 in aggregate)
In case of person with severe disability a deduction of
Rs. 1,25,000/- shall be allowed. Rs…………..
4. Medical treatment expenditure U/s 80DDB (Amount
actually paid or Rs. 40,000 whichever is less) of specified
diseases. In case of dependent Sr. Citizen (above 65 years)
amount actually paid or Rs. 60,000 whichever is less Rs…………..
5. Donations U/s 80G - 100% Rs…………..
U/s80G - 50% Rs…………..
6. Payment of interest of loan taken for higher education
U/s 80(E) Rs…………..
(Repayment of loan by assessee or for his spouse &
children’s higher education).
7. For self physical Disability U/s 80U (Rs.75,000 fixed)
In case of person with severe disability a deduction of
Rs. 1,25,000/- shall be allowed. Rs…………..
8. Contribution to New Pension Scheme
U/S 80CCD (1B) upto a maximum of Rs.50,000/- Rs…………..

I certify that all particulars given by me are correct and I will produce their authenticity.

Signature with date:

Directorate

Signature of the Controlling Officer

Name & Designation
Note : Declaration received without the signature of the controlling officer & PAN will NOT be
Entertained.
APO/Bills
 FORM NO. 12 BA
[See Rule 26A(2) (b)]

AU : BU : PF No. : PAN
Statement showing particulars of perquisites, other fringe benefits of
amenities and profits in lieu of salary with value thereof
1) Name and address of employer, DG/RDSO/Manak Nagar, Lucknow
2) Name and designation of employee:
3) Assessment year 2018-19
SN Nature of perquisite (See Rule Value of Amount if any Amount of taxable
3) perquisite as paid by perquisites (Rs.)
per rules (Rs.) employee (Rs.)
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/privilege
16. Stock options (non-qualified
options)
17. Other benefits or amenities
18. Profits in lieu of salary as per
17(3)
Total value of perquisites
Total value of profit in lieu of salary
Declaration by employee
I, S/o. working as do hereby declare that the above
information give by me are true and correct to my best of knowledge.

Place : Signature of employee

Dated : Full Name & Designation
FORM NO. 12 C
Form for sending particulars of Income U/s 192 (2B) for the year ending 31st March 2018

1. Name and address of the employee

2. Permanent Account Number
3. Residential Status
4. Particulars of income under any head of income other than ‘salaries’ (not being a loss under
any such head other than the loss under the head ‘Income from house property’) received in
the financial year.

i) Income from house property

(in case of loss, enclosed computation thereof as per enclosed annexure).
ii) Profits and gains of business or profession
iii) Capital gains
iv) Income from other sources
v) Dividends
vi) Interest
vii) Other income (specify)
Total
5. Aggregate of sub-items (i) to (iv) of item 4.
6. Tax deducted at sources (enclosed certificates issued under Section 203)

Place : Signature of the employee

Date :

VERIFICATION

I, ………………………………………………… do hereby declare that whatever is stated is

true to the best of my knowledge and belief.

Verified today, the …………………. Day of ………………………. 2017.

Place : Signature of the employee

Date :

Signature of the Controlling Officer

Designation
 ANNEXURE TO FORM NO. 12C
Research Designs & Standards Organization
Manak Nagar, Lucknow –11.
AU: BU: Dte. PF No. :
Computation sheet for claiming rebate on accrued interest on HBA for the financial year
2016-17 (Sec. 23 & 24).

I……………………………………… have taken HBA amounting to Rs…………...

Date of Sanction ………………..

I declare that the construction of the house/flat by the above HBA was completed on
…………... (date) and the same is :-
(Please fill up I & II below, as the case may be and score out the other).
I (a) (i) SELF OCCUPIED and not actually let out during any part of the financial year 2017-18
and no other benefit therefrom is derived by me. Therefore, the annual value of such a house shall
be taken to be NIL.
OR

(ii) I have only one residential house at ………………………………………………….

(address) which cannot be occupied by me owing o my posting at any other place and no other
benefit therefrom is derived by me. Therefore, the annual value of the house shall be taken to be
NIL.

Note : (1) For the above (i) & (ii) deduction on account of accrued interest is allowed upto a
maximum limit of Rs. 30,000.00
(2) In case of self occupied property acquired or constructed with capital borrowed on
or after 01.04.1999 and acquisition or construction of the house property is made
within three years from the end of the financial year in which capital was borrowed
the maximum deduction for interest shall be Rs. 2,00,000.00. For this purpose, the
assessee shall furnish a certificate from the person extending the loan that such
interest was payable in respect of loan for acquisition or construction of the house,
or as refinance loan for repayment of an earlier loan for such purpose.
(b) Accrued interest during the current financial year ……………………………
(c) Loss from house property i.e. (b) – (a) ……………………………………….
II NOT SELF OCCUPIED
(A) PARTLY LET OUT:

(a) (i) Total rent received Rs ……………………………...

(ii) Proportionate annual value (U/s 23) Rs………………………………
(b) Accrued interest during the current financial year Rs………………………………
(c) Income from house property i.e. (a) – (b) Rs………………………………

Note: (1) Please fill up both (i) & (ii) above

(2) The higher amount will be taken as annual value of the house
(3) The deduction on account of accrued interest shall not exceed the annual value.
(B) LET OUT FOR THE WHOLE YEAR

(a) (i) Annual rent received

Rs……………………………………..
(ii) Annual value (U/s. 23) Rs……………………………………..

Note: (1) Please fill up both items (i) & (ii) above.
(2) The higher amount will be taken as annual value of the house.
(3) All eligible accrued interest on HBA are allowed.

(b) Accrued interest during the current financial year Rs……………………………………..

(c) Income from house property i.e. (a)-(b) Rs……………………………………..
(d) Loss from the house property i.e. (b)-(a) Rs……………………………………..

I certify that the above information is correct and if any, information is found incorrect
later on. I will be personally responsible of the same and I shall also be liable to be taken up under
D&A Rule.

Signature

Name
Designation
Dte.
Phone No.

Signature of the Controlling Officer

Name ………………………………….

Designation ……………………………

APO/Bills
Note: Forms incomplete in any respect shall not be entertained by E-III Section.