FORM 12BB — STATEMENT OF CLAIMS FOR DEDUCTION OF TAX
Furnished by an employee under Rule 26C of the Income-tax Rules, 1962 to the employer for evidence of claims used in computing TDS on salary.
Employer: [Company Name] Financial Year: [YYYY-YY]
| Employee Name | [Employee Name] | PAN | [ABCDE1234F] |
| Employee Code | [EMP-____] | Designation | [Designation] |
| Nature of Claim | Amount (₹) | Evidence / Particulars |
|---|---|---|
| 1. House Rent Allowance (HRA) | [Amount] | Rent paid, landlord name, address & PAN (if rent > ₹1 lakh) |
| 2. Leave Travel Concession (LTA) | [Amount] | Travel bills / tickets |
| 3. Interest on Home Loan (Sec 24) | [Amount] | Lender name, address & PAN |
| 4. Deductions under Chapter VI-A: | ||
| (a) Sec 80C (LIC, PPF, ELSS, tuition, etc.) | [Amount] | [Proof] |
| (b) Sec 80D (Medical insurance) | [Amount] | [Proof] |
| (c) Sec 80E / 80G / others | [Amount] | [Proof] |
Verification: I, [Employee Name], son/daughter of [Father's Name], declare that the information given above is complete and correct.
Place: [Place] Date: [DD/MM/YYYY] _______________________
Signature of Employee
Compliance note: Employees must attach documentary evidence for each claim. Landlord PAN is mandatory where annual rent exceeds ₹1,00,000. Submit at the start of the year and finalise with actual proofs before year-end payroll processing.