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ANNUAL INCOME TAX STATEMENT FOR THE FINANCIAL YEAR 2012-2013

(Assessment Year 2013-2014)

Name, Designation and

Official Address of the

Government Servant [ in

BLOCK letters]Residential Address

Sex: Male / Female

PAN: TAN: Station

:

1 a Gross Salary Income (Include Pay, DA, HRA,

CCA, IR, etc.)

Rs. Rs. Rs.

1 March 2012

2 April 2012

3 May 2012

4 June 2012

5 July 2012

6 August 2012

7 September 2012

8 October 2012

9 November 2012

1

0

December 2012

1

1

January 2013

1

2

February 2013

b Leave Surrender

c Festival Allowance / Bonus / Food Allowance / Medical

Allowance etc.

d Pay Revision Arrears

e Value of prequisites u/s 17(2) (as per Form No. 12BA,

wherever applicable)f Profits in lieu of salary u/s 17(3) (as per Form No. 12BA,

wherever applicable)

g Total Salary income(a+b+c+d+e+f)

2 Deduct: The actual HRA received or House Rent actually

paid in excess of 10% of the pay plus DA or 50% of pay

plus DA whichever is the least in case residing in a rented

building u/s 10 (13A)

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3 Balance (1-2)

4 Deduct

a Entertainment Allowance [see 16 (ii)]

b Professional Tax paid in 2012-'13

c Any other allowance exempted u/s 10

d Total 4(a) + 4(b) + 4(c)

5 Income Chargeable under the head Salaries (3-4)

6 Add income from other sources

7 Add income from house property

8 Deduct interest/accured interest on HBA (maximun

admissible is Rs 30,000/- (if the property is acquired or

constructed on or after 01.04.99 and such acquisition or

construction is completed within three years from the

end of the financial year in which capital is borrowed,

deductible amount is 1.50 Lakh)

9 Gross Total income(5+6+7-8)

Rates of Income Tax

Individual & HUF Below age

of 65 years

Tax Rates Women below age of 65

years

Tax Rates

Income tax up to 2,00,000 Nil Income tax up to 2,00,000 Nil

Rs 2,00,001 - 5,00,000 10% Rs 2,00,001 - 5,00,000 10%

Rs 5,00,001 - 10,00,000 20% Rs 5,00,001 - 10,00,000 20%

Above Rs 10,00,001 30% Above Rs 10,00,001 30%

Education Cess: An addl. surcharge called E.C. @ 2% on the amount of income tax & surcharge (if any) in

all cases shall be leviedSecondary & Higher : An additional surcharge, called the Secondary & Higher E. C. on income tax at the

rate of 1% of income tax

Rs. Rs.

B/F

1

0

Deductions under Chapter VI A:

A Under Section 80 C

a GPF/PPF Contributions

b LIC Premium (himself/spouse/children) not exeeding

20% of total Sum assured

c GIS/FBS/SLI/PLI premium

d Contribution towards LIC's Dhanaraksha Mutual Fund

e Any annuity or Deferred Annuity plan

f Subsciption towards NSC VIII issue

g Contribution to UTI's Retirement Benefit Plan

h Investment in UTI's Unit Linked Insurance Plan

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i Approved Mutual Fund Investments u/s 10(23D)

 j Repayment of Housing Loan Principal towards self 

occupied Residential Property

k Repayment of tuition fee towards any 2 children of 

assessee

l Investment in Equity Linked Savings Scheme / ApprovedInfrastructure Bonds

m Investment in pension Fund/Deposit of National Housing

Bank under Home Loan Account Scheme

n Fixed deposit on any Scheduled Bank/Housing Finance

Company for not less than 5 years

o Amount invested in a 5 Year Post Office Term Deposit

Account

p Amount invested in a Senior Citizen Savings Schekme,

2004

B U/S 80CCC - Premium paid towards IRDA approved

Pension FundC U/S 80CCD - Pension Scheme vide Notification No.

F.N.5/7/2003 - ECB & PR dt. 22.12.03

D The aggregate amount of deduction u/s 80C, 80CCC &

80CCD(max. 1 Lakh)

1

1

U/S 80CCF

1

2

A U/S 80D - Medical insurance premium (max. 15,000)

B U/S 80DD - Maintenance including medical treatment of 

Handicaped dependent

C U/S 80DDB - Medical treatment expense (max. 40,000)

(For Senior Citizen Max. 60,000)

D U/S 80E - Payment of interest on loan taken for higher

studies

E U/S 80G - Donations made to recognized funds) Rate of 

deduction is 50%

F U/S 80GG - If an assessee not in receipt of HRA incurs

any expenditure on rent

G U/S 80 U - Disability allowance

H Any other allowance (specify)

1

3

Aggregate of deductible amount under chapter VIA

(10D+11+12A+B+C+D+E+F+G+H)1

4

Total Income (9-13)

1

4

A Total Income in multiples of Tens

1

5

a Income tax due on total income in 14 A

b Normal tax or tax under marginal releif (if income

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exceeds 10 lakhs)

1

6

Surcharge (on tax at computed at S.No 15)

1

7

a Education cess 2% (on Sl. No.15 & Sl. No.16)

b Secondary & Higher Education Cess 1% (on Sl. No.15 &Sl. No.16)

1

8

Total tax payable (15+16+17(a)+17(b))

1

9

Less: releif u/s 89, if any (attach details)

2

0

Tax Payable (18-19)

2

1

Less (a)Tax deduction at source u/s 192(1)

(b) Tax paid by employer on behalf of employee u/s

192(IA) on prequisites u/s 17 (2)2

2

Balance Tax Payable (20-21)

2

3

Remarks:

Place: Signature of the Officer in case of G.Ps /

Date: Signature of the Head of Office in case of Non G.Ps

Name :

Designation :