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
Page 1 2

Name and Address of the Employer Name and Rank of the Employee
PAO (ORs) MRC SAUGOR 6 MAHAR 72B006 032 JC570193L ACPSUB TEJ PRATAP PANDEY
PAN of the Deductor TAN of the Deductor PAN of the Employee
BAFPM3766H JBPPO1639B ANJPP3113D
CIT(TDS) Address Assessment Year Period
1(2) 2020-2021 01/04/2019 TO 31/03/2020
Summary of Tax deducted at Source
Quarter Receipt Numbers of original statements of Amount of tax deducted Amount of tax deducted/remitted
TDS under sub-section(3) of section 200 in respect of the employee in respect of the employee
Quarter 1 QTPAADMC 12026 12026
Quarter 2 QTUWDZMF 18634 18634
Quarter 3 QTVGWGVG 44240 44240
Quarter 4 QTYVKDLG 16284 16284
Total 91184 91184
PART-B
DETAILS OF SALARY PAID AND ANY OTHER INCOME AND TAX DEDUCTED
` ` ` `
1. Gross Salary * 1190410
2. Standard Deduction * 50000
3. Less Allowance to the extent exempt under Section 10 114530
4. BALANCE (1 - 2) 1025880
5. DEDUCTIONS :
a. Interest payable on loan u/s 24 : 0
6. Aggregate of 5 ( a to b ) 0
7. Income chargeable under the Head 'SALARIES' (3 - 5) 1025880
8. Add: Any other income reported by the employee 0
9. GROSS TOTAL INCOME (6 + 7) 1025880
10. DEDUCTIONS UNDER CHAPTER VI-A GROSS AMT QUAL AMT QUAL AMT DEDUCT AMT
a) Qualified under Sec.80C 192028 150000 150000
b) Qualified for 100% deduction 0 0 0
c) Qualified for 50% deduction 0 0 0
d) Qualified under Sec.80DD 0 0 0
e) Qualified under Sec.80U 0 0 0
11. Aggregate of deductible amount under Chapter VI-A 150000
12. Total Income (8 - 10) Rounded 875880
13. TAX ON TOTAL INCOME 87676
14. Health & Education Cess @4% (on tax computed at Sl.No.12) 3508
15. Tax Payable (12 + 13) 91184
16. Less: Relief under Section 89(attach Details) 0
17. Less : Tax Deducted 91184
18. TAX PAYABLE/REFUNDABLE (15 - 16) 0

VERIFICATION

I, KESH RAM MEENA, son/daughter of GIRWAR LAL MEENA working in the capacity of AAO do
hereby certify that a sum of Rs. 91184 (in words) Rupees Ninety One Thousand One Hundred Eighty Four only.
has been deducted and deposited to the credit of Central Government. I further certify that the above information
is true, complete and correct and is based on the books of account, documents, TDS statements, TDS deposited
and other available records.

Note : Health and Education Cess @4% Charged On Income Tax (Rounded off to next higher rupee)

Place : SAUGOR Signature of the person responsible for deduction of tax

Name and Address of the Employer Name and Rank of the Employee
PAO (ORs) MRC SAUGOR 6 MAHAR 72B006 032 JC570193L ACPSUB TEJ PRATAP PANDEY
For the financial year from 01/03/2017 to 28/02/2018 = -18827.0
For the financial year from 01/03/2018 to 28/02/2019 = 56934.0
For the financial year from 01/03/2019 to 29/02/2020 = 1152303.0
Total taxable emoluments 1190410.0