DECLARATION AS TO BENEFICIAL OWNERSHIP

loan amounting to Rs.136217

hereby declare that the deduction in respect of interest on housing
amount Rs. 253783 for the financial year 2021-22
is not claimed by any
and repayment of principal
share in the
other person and I am the 100 % beneficial owner(Please indicate the proportionate
beneficial ownership amongst the Co-owner of the property)

e ( Is04)

Employee Signature
DebrmibaVand 0

Signature of the Co-Owner

Employee Name: Devraj Dash

Date:4th Jan 2022

Employee No: H161845
 FORM NO. 12C
See rule 26B]

Form for sending particulars of income under section 192(2B) for

the year ending 31st March, 2022
1.Name and address of the employee Devraj Dash
2.Permanent Account Number AWJPD8433F
3.Residential status India
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
Income from house property
(in case of loss, enclose computation thereof as per annexure to form 12C) Rs.(136217)
(ii) Profits and gains of business or profession Rs.
(i) Capital gains Rs
(v) Income from other sources Rs.

a) Interest Rs.

b) Other incomes (specify) Rs.

Rs. TOTAL Rs.(136217)

of sub-items (i) to (iv) of item 4

5. Aggregate
[enclose certificate(s) issued under
section 203]
6. Tax deducted at source

Bangalore e v r

Place
y Jan-202 2 Signature of the employee
Date

Verification the best of my knowledge and

belief.
Dash do hereby declare that what is stated above is true to
I, Devraj , 2022.
Verified today, the un _day of an
e D
Place Bangaloe
Signature of the employee
Date U J a n 2022
 Annexure to Form 12C

Details of Loss form House Property: use appropriate column in case employee owns more than one house then other column
can be used.

PARTICULARS PROPERTY 1 PROPERTY 2 PROPERTY 3

SELF-OCCUPIED (LET-OUT) (LET-OUM

| Name of the borrower Devraj Dash

Property situated at with full address including Flat No AG02 Sekhar
District and State. Bellevue, balagere road
Bangalore 560087
Details of Co-borrowers sharein the Property. Debamitra Panda
Whether the Co-borrower is claiming deduction for No
Principal repayment and Interest, if so provide the
details of each Co-borrower's%of claim.
Date of Takingloan 16/08/2016
Date of completion of construction of house | NA
Date of occupancy of house 14/11/2017
Interest payable during the construction period
(1)EMI Interest for 2021-22 136217
253783
(2)EMI Principal for 2021-22

(3) Figures to match with bank's

certificate)
Total interest for 2021-22 136217
If loan is taken before 1st April 1999-30,000/-
Ifloanistaken after 1st April 1999-1,50,000
NA
B-DETAILS REQUIRED WHEN HOUSE IS GIVEN
ON RENT& LOAN IS TAKEN FOR SAME (See Note)

Name of the borrOwer

Property situated at with full address including
District and State.
| Details of Co-borrowers share in the Property._
for
Whether the Co-borrower is claiming deduction
if provide the
Principal repayment and Interest,
so

details of each Co-borrower's % of claim.

Annual Rent received
Less Municipal taxes actually paid like water, Fire,
Cess, Sewage tax
Net Annual Value(NAV)
Less:1. Standard Deduction (30% of NAV)
2. Interest on Borrowed Capital
(Noceiling of 30,000/1,50,000/-.
Taxable Property Income

Note:- Details required when house is rented

(1) Name of the borrower Pe De
(2)Date of taking loan
(3)Annual Rent earned
41ss Municipal taxes paid Employee Signature
99Annual value