FORM NO. 123 [See rule 204(2)(b)] Statement showing particulars of perquisites, other fringe benefits or amenities and profits in lieu of salary with value thereof
| Row No. | Part A: Details of the employer | ||
|---|---|---|---|
| 1. | Name | (refer Note 1) | |
| 2. | Address | (refer Note 2) | |
| 3. | Permanent Account Number | ||
| 4. | Tax deduction/collection account number | ||
| 5. | Email id | ||
| 6. | Contact number | Country Code | Number |
| Details of the employee | |||
| 7. | Name | (refer Note 1) | |
| 8. | Designation | ||
| 9. | Permanent Account Number | ||
| 10. | Is the employee a director or a person with substantial interest in the company (Applicable where the employer is a company) | Yes/No | |
| 11. | Income under the head ―Salaries‖ of the employee (other than from perquisites) | ||
| 12. | Email id | ||
| 13. | Contact number | Country Code | Number |
| 14. | Tax year |
| Part B: Valuation of perquisites | ||||
|---|---|---|---|---|
| Row No. | Nature of perquisites (see rule 15) | Value of perquisite as per rules | Amount, if any, recovered from the employee | Amount of perquisite chargeable to tax Col. (C) - Col. (D) |
| A | B | C | D | E |
| 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 allotted or transferred by employer being an eligible start-up referred to in section 140 | |||
| 17 | Stock options (non-qualified options) other than ESOP in col 16 above. | |||
| 18 | Contribution by employer to fund and scheme taxable under section 17(1) (h) | |||
| 19 | Annual accretion by way of interest, dividend etc. to the balance at the credit of fund and scheme referred to in section 17(1)(i) | |||
| 20 | Other benefits or amenities | |||
| 21 | Total value of perquisites | |||
| 22 | Total value of profits in lieu of salary as per section 18 | |||
| 23 | Details of tax, — | |||
| (a) Tax deducted from salary of the employee Section 392 - Salary and Accumulated Balance Due to an Employee section 392(1) | ||||
| (b) Tax paid by employer on behalf of the employee under Section 392 - Salary and Accumulated Balance Due to an Employee section 392(2)(a) | ||||
| (c) Total tax paid [23(a) + 23(b)] | ||||
| (d) Date of payment into Government treasury |
DECLARATION
I, ……………………….. , having Permanent Account Number …………………… working as…………….
(designation) do hereby declare on behalf of ……………… (name of the employer) that the information given above
is based on the books of account, documents and other relevant records or information available with us and the
details of value of each such perquisite are in accordance with section 17, profits in lieu of salary in accordance with
section 18 of Act and rules framed thereunder and that such information is true and correct.
Place: ………… Signature of the person responsible for
deduction of tax
Date: ………… Name:
Designation:
Notes
- In case of individual, the first, middle and last name shall be provided in full without any abbreviations. In any other case also, name shall be provided in full.
- The address shall contain i. Country/Region, ii. Flat/Door/Block number iii. Road/Street/Block/Sector, iv. PIN/ZIP Code, v. Post Office, vi. Area/locality, vii. District, viii. State.
- Amounts to be filled in ₹ unless otherwise provided.