Samsung India Electronics Pvt. Ltd.

Form 16

(Digitally Signed Document)

Assessment Year 2014-15

Employee Name

Sagun Pratap Singh

Employee PAN

BLKPS3597J

Employee Code

13638462

Employee Designation

Assistant Manager (1)

Period With The Employer

From : 01-Aug-2013 To : 31-Mar-2014

Note on Digital Signature:

This Form-16 document has been digitally signed with a Digital Signature Certificate as allowed under
section 119 of the Income-Tax Act, 1961. Refer Circular No.2/2007, Dated 21-May-2007 for details.
Affixing of Digital Signature means that a secure cryptographic procedure has been applied to the entire
contents of this document and a unique digital signature (equivalent to affixing of hand written signature)
has been embedded in this document.To view and validate the digital signature details, please click on the
digital signature affixed below.

Signature Details:
Digitally Signed by : JAI PARKASH SHARMA

Signature Not Verified

SHARMA JAI PARKASH
31.05.2014 12:18

FORM NO. 16
[See rule 31(1)(a)]

PART A
Certificate under Section 203 of the Income-tax Act, 1961 for tax deducted at source on salary
Certificate No. RZCZJHH

Last updated on

Name and address of the Employer

21-May-2014

Name and address of the Employee

SAMSUNG INDIA ELECTRONICS PRIVATE LIMITED

A-25, GROUND FLOOR, FRONT TOWER,
MOHAN COOPERATIVE INDUSTR, NEW DELHI - 110044
Delhi
+(91)11-43661234
[email protected]

SAGUN PRATAP SINGH

H NO 791, PASHCHIM PURI, SIKANDRA, AGRA - 283105 Uttar
Pradesh

PAN of the Deductor

TAN of the Deductor

AAACS5123K

DELS19222A

PAN of the Employee

Employee Reference No.

provided by the Employer
(If available)

BLKPS3597J

CIT (TDS)

Assessment Year

The Commissioner of Income Tax (TDS)

Aayakar Bhawan, District Centre, 6th Floor Room no 610, Hall no.
4 , Luxmi Nagar, Delhi - 110092

2014-15

Period with the Employer

From

To

01-Apr-2013

31-Mar-2014

Summary of amount paid/credited and tax deducted at source thereon in respect of the employee

Quarter(s)

Receipt Numbers of original

quarterly statements of TDS
under sub-section (3) of
Section 200

Q2

XNBXBYAB

92892.00

Q3

QASTCBJC

150629.00

0.00

0.00

Q4

QQPTMSNE

209804.00

11905.00

11905.00

453325.00

13477.00

13477.00

Total (Rs.)

Amount of tax deposited / remitted

(Rs.)

Amount of tax deducted

(Rs.)

Amount paid/credited

1572.00

1572.00

I. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH BOOK ADJUSTMENT
(The deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)
Book Identification Number (BIN)
Sl. No.

Tax Deposited in respect of the

deductee
(Rs.)

Receipt Numbers of Form

No. 24G

DDO serial number in Form no.

24G

Date of transfer voucher Status of matching

(dd/mm/yyyy)
with Form no. 24G

Total (Rs.)
II. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN
(The deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)

Sl. No.

Tax Deposited in respect of the

deductee
(Rs.)

1572.00

Challan Identification Number (CIN)

BSR Code of the Bank
Branch

Date on which Tax deposited Challan Serial Number

(dd/mm/yyyy)

Status of matching with

OLTAS*

6910333

07-09-2013

15764

0.00

07-10-2013

0.00

07-11-2013

0.00

07-11-2013

0.00

06-12-2013

Page 1 of 2

Certificate Number: RZCZJHH

Sl. No.

TAN of Employer: DELS19222A

Tax Deposited in respect of the

deductee
(Rs.)

0.00

2050.00

0.00

PAN of Employee: BLKPS3597J

Assessment Year: 2014-15

Challan Identification Number (CIN)

BSR Code of the Bank
Branch

Date on which Tax deposited Challan Serial Number

(dd/mm/yyyy)

Status of matching with

OLTAS*

07-01-2014

6910333

07-02-2014

13773

07-02-2014

7805.00

6910333

07-03-2014

16704

10

2050.00

6910333

30-04-2014

10629

Total (Rs.)

13477.00
Verification

I, JAI PARKASH SHARMA, son / daughter of VED PRAKASH SHARMA working in the capacity of ASSTT MANAGER TAXATION (designation) do hereby certify that a
sum of Rs. 13477.00 [Rs. Thirteen Thousand Four Hundred and Seventy Seven Only (in words)] has been deducted and a sum of Rs. 13477.00 [Rs. Thirteen
Thousand Four Hundred and Seventy Seven Only] has been deposited to the credit of the Central Government. I further certify that the information given above is
true, complete and correct and is based on the books of account, documents, TDS statements, TDS deposited and other available records.

Place

New Delhi

Date

27-May-2014

Designation: ASSTT MANAGER TAXATION

(Signature of person responsible for deduction of Tax)

Full Name:JAI PARKASH SHARMA

Notes:
1. Part B (Annexure) of the certificate in Form No.16 shall be issued by the employer.
2. If an assessee is employed under one employer during the year, Part 'A' of the certificate in Form No.16 issued for the quarter ending on 31st March of the financial year shall contain the details
of tax deducted and deposited for all the quarters of the financial year.
3. If an assessee is employed under more than one employer during the year, each of the employers shall issue Part A of the certificate in Form No.16 pertaining to the period for which such
assessee was employed with each of the employers. Part B (Annexure) of the certificate in Form No. 16 may be issued by each of the employers or the last employer at the option of the assessee.
4. To update PAN details in Income Tax Department database, apply for 'PAN change request' through NSDL or UTITSL.

Legend used in Form 16

* Status of matching with OLTAS
Legend

Description

Definition

Unmatched

Deductors have not deposited taxes or have furnished incorrect particulars of tax payment. Final credit will be reflected only when payment
details in bank match with details of deposit in TDS / TCS statement

Provisional

Provisional tax credit is effected only for TDS / TCS Statements filed by Government deductors."P" status will be changed to Final (F) on
verification of payment details submitted by Pay and Accounts Officer (PAO)

Final

In case of non-government deductors, payment details of TDS / TCS deposited in bank by deductor have matched with the payment details
mentioned in the TDS / TCS statement filed by the deductors. In case of government deductors, details of TDS / TCS booked in Government
account have been verified by Pay & Accounts Officer (PAO)

Overbooked

Payment details of TDS / TCS deposited in bank by deductor have matched with details mentioned in the TDS / TCS statement but the
amount is over claimed in the statement. Final (F) credit will be reflected only when deductor reduces claimed amount in the statement or
makes new payment for excess amount claimed in the statement

Page 2 of 2

PART B
DETAILS OF SALARY PAID AND ANY OTHER INCOME AND TAX DEDUCTED

Particulars

Rs.

1.GROSS SALARY (As per enclosed annexure)

(a) Salary as per provisions contained in section 17(1)
(b) Value of perquisites under section 17(2)
(as per Form No.12BA, wherever applicable)
(c) Profits in lieu of salary under section 17(3)
(as per Form No.12BA, wherever applicable)
(d) Total

Rs.

Rs.

4,49,929.00
0.00
0.00
4,49,929.00

2.Less: Allowance to the extent exempt u/s 10

(As per enclosed annexure)
3.Balance(1-2)

78,070.00
3,71,859.00

4.DEDUCTIONS:
(a) Entertainment Allowance
(b) Tax on Employment

0.00
1,600.00

5.Aggregate of 4 (a) and (b)

1,600.00

6.INCOME CHARGEABLE UNDER THE HEAD SALARIES(3-5)

3,70,259.00

7.Add: Any other income reported by the employee

(a) Income under the Head Income from House Property
(b) Income under the Head Income from Other Sources

0.00
0.00

8.GROSS TOTAL INCOME ( 6+7 )

3,70,259.00

9.DEDUCTIONS UNDER CHAPTER VI-A

(A) Sections 80C,80CCC and 80CCD
(a) Section 80C
Life Insurance Premium
Public Provident Fund
Employee Provident Fund

Gross Amount

(b) Section 80CCC

(c) Section 80CCD
Total of (a)+(b)+(c)
(B) Other Sections under Chapter VI-A
(a) 80CCG
(b) 80D
(c) 80DD
(d) 80DDB
(e) 80E
(f) 80EE
(g) 80G
(h) 80TTA
(i) 80U

Rajiv Gandhi Equity Savings Scheme

Medical Claim
Handicapped Dependents
Medical Expenses, Chronic Diseases
Education loan repayment
Interest on loan for residential property
Donation
Interest on Savings Bank Account
Permanent Physical disability

Sagun Pratap Singh /13638462/1

Deductible Amount

51,952.00
20,000.00
21,504.00

51,952.00
20,000.00
21,504.00

0.00
0.00

0.00
0.00
93,456.00

Gross Amount

Qualifying Amount

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Deductible Amount

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

10.Aggregate of deductible amount under Chapter VI-A

11.Total Income (8-10)

93,456.00
2,76,800.00

12.Tax On Total Income

13.Less: Tax Rebate u/s 87A
14.Surcharge @ 10% (on tax computed at S. No. 12)
15.Education cess @ 3% (on (12-13+14))
16.Tax Payable(12-13+14+15)
17.Less: Relief under section 89
18.Tax Payable (16-17)

7,680.00
2,000.00
0.00
170.00
5,850.00
0.00
5,850.00

Verification
I, JAI PARKASH SHARMA, son of Sh VED PRAKASH SHARMA working in the capacity of ASSTT MANAGER TAXATION, do hereby certify
that the information given above is true, complete and correct and is based on the books of account, documents, TDS statement, TDS deposited
and other available records,which includes the declaration given by the employee.

Place :New Delhi

Date :31-May-2014

Sagun Pratap Singh /13638462/2

For Samsung India Electronics Pvt. Ltd.

Signature of the person responsible for deduction of tax
(Digitally Signed Document)
Full Name : JAI PARKASH SHARMA
Designation : ASSTT MANAGER TAXATION

FORM No.12BA
{See Rule 26A(2)(b)}
Statement showing particulars of perquisites, other fringe benefits or
amenities and profits in lieu of salary with value thereof
1) Name and Address of the Employer :
Samsung India Electronics Pvt. Ltd.
A 25, GROUND FLOOR, FRONT TOWER,
MOHAN COOPERATIVE INDUSTR NEW DELHI 110044
2) TAN:
3) TDS Assessment Range of the Employer :

DELS19222A
IT Ward (51)

4) Name of Employee:
Designation:
PAN:
5) Is the employee a director or a person with substantial interest
in the company (Where the employer is a company):
6) Income under the Head Salaries of the Employee :
(Other than from perquisites)
7) Financial Year :
8) Valuation of Perquisites

Sagun Pratap Singh

Assistant Manager (1)
BLKPS3597J

Sr No.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

Nature of perquisite

Accommodation
Cars/Other automotive
Medical
Hotel
Interest free or concessional loans
Holiday expenses
Free or concessional travel
Free meals
Free Education
Gifts,vouchers etc.
Credit card
Club expenses
Use of movable assets by employee
Transfer of assets to employee
Value of any other benefit/amenity/service/privilege
Stock options
Other benefits or amenities
Total Value of Perquisites
Value of profits in lieu of salary as per section 17 (3)

No
3,70,259.00
2013-14

Value of perquisite

Amount, if any paid

Amount of Taxable

as per rules(Rs.)

by employee(Rs.)

perquisite(Rs.)

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

9) Details of tax
(a) Tax Deducted from Salary of Employee u/s 192(1)
(b) Tax Paid by Employer on behalf of Employee u/s 192(1A)
(c) Total tax paid
(d) Date of payment into Government treasury

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

13,477.00
0.00
13,477.00
Refer Form16

DECLARATION BY EMPLOYER
I, JAI PARKASH SHARMA, son of Sh VED PRAKASH SHARMA working in the capacity of ASSTT MANAGER TAXATION, do hereby declare
on behalf of Samsung India Electronics Pvt. Ltd., 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.

Place :New Delhi

Date :31-May-2014

Sagun Pratap Singh /13638462/3

For Samsung India Electronics Pvt. Ltd.

Signature of the person responsible for deduction of tax
(Digitally Signed Document)
Full Name : JAI PARKASH SHARMA
Designation : ASSTT MANAGER TAXATION

ANNEXURE TO FORM NO.16

Details of Salary Paid and Allowance Exempted u/s 10 and 17(2) of Income-tax Act,1961
1) Name and Address of the Employer:
Samsung India Electronics Pvt. Ltd.
A 25, GROUND FLOOR, FRONT TOWER,
MOHAN COOPERATIVE INDUSTR NEW DELHI 110044
2) Name of Employee:
Designation:
PAN:
Employee Code:

Sagun Pratap Singh

Assistant Manager (1)
BLKPS3597J
13638462

Salary Details for the period: 01-Aug-2013 to 31-Mar-2014

1. Salary as per provisions contained in Sec 17(1)
BASIC
HRA
CONV. ALLOWANCE
SPL. ALLOWANCE
INCENTIVE
EXGRATIA
MGT ALLOWANCE

1,79,176.00
89,592.00
37,960.00
26,880.00
67,070.00
11,291.00
37,960.00

Total Salary (A)

4,49,929.00

Value of perquisites u/s 17(2)

(as per Form No.12BA,wherever applicable)

0.00

Profits in lieu of Salary u/s 17(3)

(as per Form No.12BA,wherever applicable)

0.00

Total Perquisites (B)

0.00

Gross Salary (A+B)

2. Details of Allowance exempted under section 10 and 17(2)
HRA
CONVEYANCE

Total (C)
3. Balance : (A+B-C)

Place :New Delhi

Date :31-May-2014

Sagun Pratap Singh /13638462/4

4,49,929.00
71,670.00
6,400.00

78,070.00

78,070.00
3,71,859.00

For Samsung India Electronics Pvt. Ltd.

Signature of the person responsible for deduction of tax
(Digitally Signed Document)
Full Name : JAI PARKASH SHARMA
Designation : ASSTT MANAGER TAXATION