FORM NO. 124 [See rule 205] Statement showing particulars of claims by an employee for deduction of tax under section 392(5)(b)
| Part A: Details of the employee | |||
|---|---|---|---|
| 1. | Name of the employee | (refer Note 1) | |
| 2. | Address | (refer Note 2) | |
| 3. | Permanent Account Number | ||
| 4. | Email id | ||
| 5. | Contact number | Country Code | Number |
| 6. | Tax Year |
| Part B: Details of claims and evidence thereof | ||
|---|---|---|
| Nature of claim | Particulars | |
| 1. | House Rent Allowance: | |
| (i) Name of the landlord | ||
| (ii) Address | ||
| (iii) Permanent Account Number (refer Note 3) | ||
| (iv) Aadhaar Number | ||
| (v) Relationship with the landlord, if any | ||
| (vi) Rent paid to the landlord | ||
| (repeat details of Row No. 1 if required) | ||
| 2. | Leave travel concessions or assistance | |
| 3. | Deduction of interest on borrowing: | |
| (i) Name of the lender | ||
| (ii) Address | ||
| (iii) Permanent Account Number of | ||
| (a) Financial Institutions (if available) or | ||
| (b) Employer (if available) or | ||
| (c) Others | ||
| (iv) Interest payable/paid to the lender | ||
| (repeat details of Row No. 3 if required) | ||
| 4. | Deduction under Chapter VIII-A and B of the Act | |
| (i) Section 123 and 124 (a) Section 123 A. ………………….. B. ………………….. C. ………………….. (b) Section 124 (c) Section 130 (d) Section 131 |
| (e) Other sections (e.g. 129, 133, 137, 153, etc.) un- der Chapter VIII- A and B of the Act (a) Section …. (b) Section …. (c) Section …. | ||
|---|---|---|
| 5. | Other details to be attached as annexure | (refer Note 4) |
DECLARATION I, ………………….., having Permanent Account Number ……………. do hereby certify that the information given above is complete and correct.
Place: Signature of the employee:………………
Date: Name: …………………
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/Block number iii. Road/Street/Block/Sector, iv. PIN/ZIP Code, v. Post Office, vi. Area/locality, vii. District, viii. State.
- Permanent Account Number shall be furnished if the aggregate rent paid during the Tax Year exceeds one Lakh rupees.
- The following details shall be provided as annexures, namely:
| Annexure | Particulars |
|---|---|
| A-1 | House rent agreement |
| A-2 | Documents in support of claim of Leave travel concessions or assistance |
| A-3 | Loan agreement |
| A-4 | Documents in support of claim of deduction under Chapter VIII-A and B of the Act |
- Amounts to be filled in ₹ unless otherwise provided.