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T4301220 Dec 2023 FY2024495245

Tax Proof FY 23-24

RefNo:43012
Employee Code 495245 Name Shyam Kumar KUSHWAHA

Department GFC PAN

Unit Linked Insurance Plan

Declared Proof Cleared Remarks

80000 80000

Amoun
t
Number of Amoun Payabl
Name of Number of Installmen t Paid e on or
the Installmen t Payable on or before Total
Insuranc Date of t Paid on on or after 31st Amount FY
e Commenceme Sum or after before 1st Apr Mar 23-24 (Paid
Compan Policy nt Assure Premiu Frequenc 1st Apr 23 31st Mar 23(Amt 24(Amt Amt+Payabl Relationshi
y No. (dd/mm/yyyy) d m Amt y (Count) 24 (Count) ) ) e Amt) p

HDFC 18269687 06/07/2015 800000 80000 Yearly 1 0 80000 0 80000 Self

Standard
Life
Insurance
Company
Limited

Rent

Landlord
Rent Rental Other Rental Rental Landlord Landlord PAN Landlord Landlord Landlord Address
Month Location Location Amount Address Name 1 1 Address 1 Name 2 PAN 2 2

April

May

June Bangalore 72000 Flat no.03,2nd S Harini ACVPH9384H No.30, Lakshmi

Floor 1st Nivasa,20th R
House, Near HT Cross,
Pole, Bhuvaneshwari
Bhuvaneshwari Nagar Bengaluru,
Nagar, Karnataka,
Bengaluru, India,560024
Karnataka,
India,560024

July

August

September Bangalore 72000 No.30, Lakshmi S Harini ACVPH9384H No.30, Lakshmi

Nivasa,20th R Nivasa,20th R
Cross, Cross,

Employee Code : 495245 Date : 20 Dec 2023

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Bhuvaneshwari Bhuvaneshwari
Nagar NagarBengaluru,
Bengaluru, Karnataka,
Karnataka, India,560024
India,560024

October

November

December Bangalore 72000 Flat no.03,2nd S Harini ACVPH9384H No.30, Lakshmi

Floor 1st Nivasa,20th R
House, Near HT Cross,
Pole, Bhuvaneshwari
Bhuvaneshwari Nagar,
Nagar, Bengaluru,
Bengaluru, Karnataka,
Karnataka, India,560024
India,560024

January

February

March Bangalore 72000 Flat no.03,2nd S Harini ACVPH9384H No.30, Lakshmi

Floor 1st Nivasa,20th R
House, Near HT Cross,
Pole, Bhuvaneshwari
Bhuvaneshwari Nagar,
Nagar, Bengaluru,
Bengaluru, Karnataka,
Karnataka, India,560024
India,560024

Employee Code : 495245 Date : 20 Dec 2023

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FORM NO. 12BB

(See rule 26C)
Statement showing particulars of claims by an employee for deduction of tax under section 192

1. Name and address of the employee: Shyam Kumar KUSHWAHA

2. Permanent Account Number of the employee:

3. Financial year: 2023 - 2024

Details of claims and evidence thereof

SI.No Nature of claim Amount Evidence / particulars

(Rs.)

(1) (2) (3) (4)

1. House Rent Allowance:

(i) Rent paid to the landlord 288000

(ii) Name of the landlord

1. S Harini

(iii) Address of the landlord

1. No.30, Lakshmi Nivasa,20th
R Cross, Bhuvaneshwari
Nagar, Bengaluru,
Karnataka, India,560024

(iv) Permanent Account Number of the landlord

1. ACVPH9384H

Note: Permanent Account Number shall be furnished if the

aggregate rent paid during the previous year exceeds one lakh
rupees

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. Deduction under Chapter VI-A

(A) Section 80C,80CCC and 80CCD

Employee Code : 495245 Date : 20 Dec 2023

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(i) Section 80C

Unit Linked Insurance Plan 80000

(ii) Section 80CCC

(iii) Section 80CCD

(B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A.

Verification

I, Shyam Kumar KUSHWAHA ,son/daughter of ____________________ do hereby certify that the information given above is complete and
correct.

Place : Bengaluru/Embassy Bldg

Date : 20/12/2023 (Signature of the employee)
Designation : FP & A Analyst Full Name: Shyam Kumar KUSHWAHA

Employee Code : 495245 Date : 20 Dec 2023