FORM NO. 122 [See rule 204(1)] Form for furnishing details of income under section 392(4)(a) for the purposes of making deduction where income is chargeable under the head “Salaries”
| Sl. No. | Part A: Particulars of the employee | |
|---|---|---|
| 1. | Name | (refer Note 1) |
| 2. | Address | (refer Note 2) |
| 3. | Permanent Account Number | |
| 4. | Residential Status | (refer Note 3) |
| 5. | Tax Year |
| PART B | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Particulars of Income under head ―Salaries‖ due or received from any other employer(s) for the purpose of Section 392 - Salary and Accumulated Balance Due to an Employee section 392(4)(a)(i) | ||||||||||
| Sl. No . | Name of other employ er (s) | Permane nt Account Number of other employer (s) | Tax Collection and Account Number of other employer( s) | Period of employme nt | Particulars of salary as defined in section 16, 17 and 18, paid or due to be paid to the employee during the year | Total of column s 6, 7 and 8 | Amount deducted in respect of life insurance premium, provident fund contributio n, etc., to which section 123 applies (give details) | Total amount of tax deducte d during the year [enclose certificat e issued under section 395(4)] | ||
| Total amount of salary excludin g amounts required to be shown in columns 7 and 8 | Total amount of house rent allowance , conveyan ce allowance and other allowance s to the extent chargeabl e to tax [See Schedule III (Table S. No. 11) read with rule 279 and Schedule III (Table: Sl. No. 12) and Schedule III (Table: Sl. No. 13)] | Value of perquisite s and amount of accretion to employee ‘s provident fund account (give details in the Annexure ) | ||||||||
| (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) | (10) | (11) |
Signature of the employee ………………………………………………
| PART C | |
|---|---|
| Details of particulars for the purpose of Section 392 - Salary and Accumulated Balance Due to an Employee section 392(4)(a)(iii), (iv) and (v) | |
| Sl. No. | Particulars |
| 1. | Loss under the head ―Income from house property‖ Amount of loss Details (a) (b) |
| 2. | Details of any other income chargeable to tax under any other head of income, (not being a loss except ―loss under house property‖ reported in Table no. 1 above) – Income chargeable to tax under Nature of Amount of income received/ Any other relevant head Income credited details (a) (b) (c) (d) |
| 3. | Details of other Tax Deducted at Source – Section under Name of Address Tax Amount Amount of Whether Any other which tax deductor of Deduction of tax income amount relevant deducted at deductor and deducted received/ mentioned in details source Collection credited column (f) is Account included in Sl. Number of No. 2 above deductor (Yes/ No) (a) (b) (c) (d) (e) (f) (g) (h) |
| 4. | Details of Tax Collected at Source – Section under which tax Name of Address Tax Amount of Any other collected at source collector of Deduction tax collected relevant collector and details Collection Account Number of collector (a) (b) (c) (d) (e) (f) |
| Amount of loss | Details |
|---|---|
| (a) | (b) |
| Income chargeable to tax under head | Nature of Income | Amount of income received/ credited | Any other relevant details |
|---|---|---|---|
| (a) | (b) | (c) | (d) |
| Section under which tax deducted at source | Name of deductor | Address of deductor | Tax Deduction and Collection Account Number of deductor | Amount of tax deducted | Amount of income received/ credited | Whether amount mentioned in column (f) is included in Sl. No. 2 above (Yes/ No) | Any other relevant details |
|---|---|---|---|---|---|---|---|
| (a) | (b) | (c) | (d) | (e) | (f) | (g) | (h) |
| Section under which tax collected at source | Name of collector | Address of collector | Tax Deduction and Collection Account Number of collector | Amount of tax collected | Any other relevant details |
|---|---|---|---|---|---|
| (a) | (b) | (c) | (d) | (e) | (f) |
DECLARATION I, ……………………………………………………, having Permanent Account Number ………… do hereby de- clare that what is stated above is true to the best of my information and belief.
Place:
………………………………
Date:
Signature of the employee
N
a
Notes:
- In case of individual, the first, middle and last name shall be provided in full without any abbreviations.
- The address shall contain i. Country/Region, ii. Flat/Door/Building, iii. Road/Street/ Block/Sector, iv. PIN/ZIP Code, v. Post Office, vi. Area/locality, vii. District, viii. State.
- Fill ‗residential status‘ as (i) Resident (ii) Non-resident (iii) Resident but not ordinarily resident.
- Amounts to be filled in ₹ unless otherwise provided.
ANNEXURE [See column 8 (PART B) of the Form] Particulars of value of perquisites and amount of accretion to employee’s provident fund account
| Value of rent-free accommodation or value of any concession in rent for the accommodation provided by the employer (give basis of computation) <[See rule 15]> | ||||||
|---|---|---|---|---|---|---|
| Where accommodation is unfurnished | Where accommodation is furnished | Rent, if any, paid by the employee | Value of perquisite (column 1 minus column 6 or column 5 minus column 6 as may be applicable) | |||
| Value as if accommodation is unfurnished | Cost of furniture* OR hire charges, if hired from a third party | Perquisite value of furniture (12% of column 3) OR actual hire charges payable | Total of columns 2 and 4 | |||
| (1) | (2) | (3) | (4) | (5) | (6) | (7) |
*(including television sets, radio sets, refrigerators, other household appliances and air- conditioning plant or equipment)
ANNEXURE (Contd.)
| Whether any conveyance facility has been provided by the employer free or at a concessional rate, or where the employee is allowed the use of one or more motor cars owned or hired by the employer, the estimated value of perquisite (give details) [See rule 15] | Remuneration paid by employer for Domestic and/or personal services provided to the employee (give details) [See rule 15] | Value of free or concessional passages on home leave and other travelling to the extent chargeable to tax (give details) [See rule 278 read With Schedule III (Table S. No. 8)] | Estimated value of any other benefit or amenity provided by the employer, free of cost or at concessional rate not included in the preceding columns (give details), e.g., supply of gas, electricity or water for household consumption, free educational facilities, transport for family, etc. [See rule 15] | Employer’s contribution to recognised provident fund in excess of 12% of the employee’s salary [See Schedule XI – Part A] | Interest credited to the assessee’s account in recognised provident fund in excess of the rate fixed by the Central Government [See Schedule XI – Part A] | Total of columns 7 to 13 carried to column 8 of Part B of this Form |
|---|---|---|---|---|---|---|
| (8) | (9) | (10) | (11) | (12) | (13) | (14) |
..…………….. Signature of the employee