Form No.12BA

FORM NO.12BA

See Rule 26A(2)

as inserted by

the Income-tax (22nd Amendment) Rules, 2001, 25th September, 2001

Statement showing particulars of perquisites, other fringe
benefits or amenities and profits in lieu of salary with value thereof

1) Name and address of employer : ___________________________________________________________________________

2) Name and designation of employee : ________________________________________________________________________

3) Assessment Year: ______________

S.No	Nature of perquisite (see rule 3)	Value of perquisite as per rules (Rs.)	Amount, if any paid by employee (Rs.)	Amount of taxable perquisite (Rs.)
1	Accommodation
2	Cars
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	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	Stock options (non-qualified options)
16	Other benefits or amenities
17	Profits in lieu of salary as per 17(3)
	Total value of perquisites
	Total value of profits in lieu of salary

DECLARATION BY EMPLOYER

I ЕЕЕЕЕЕ. S/o ЕЕЕЕЕЕЕ. working as ЕЕЕЕЕЕЕЕЕЕЕ(designation) do hereby declare on behalf of ЕЕЕЕЕ..Е.. (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 and rules framed thereunder and that such information is true and correct.

Signature of the person responsible

for deduction of tax

PlaceЕ

DateЕ

Full Name ЕЕЕЕЕЕЕЕ

Designation ЕЕЕЕЕЕЕ.

	FORM NO.12BA
	See Rule 26A(2)
	as inserted by
the Income-tax (22nd Amendment) Rules, 2001, 25th September, 2001