This document is a Form 16 issued by an employer in India to an employee named Dipak Khatavkar for the assessment year 2013-2014. It summarizes the taxes deducted from the employee's salary of Rs. 360,000 over four quarters totaling Rs. 4,120. It also provides details of other income and deductions to calculate the total taxable income of Rs. 240,000 and a tax payable of Rs. 4,120.

1. Form 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
Name and Address Of Employer Name and Designation Of Employee
india dipak khatavkar
mumbai teater
PAN Of Deductor TAN Of Deductor PAN Of Employee
gdfgs5677s ssss77777d PAN NOT AVIALABLE
Assessment Year Period
CIT (TDS)
mumbai 2013-2014 From To
01/04/2012 31/03/2013
Summary Of Tax Deducted At Source
Receipt Numbers Of Original Statements Of Amount Of Tax Amount Of Tax Deposited
Quarter TDS Under Section Deducted In Remitted In Respect Of
Respect Of Employee Employee
Q1 ASDFGRTH 1029.0 1029.0
Q2 KHKSDF 1030.0 1030.0
Q3 SDFSDGDF 1031.0 1031.0
Q4 SDFSDFSDF 1030.0 1030.0
Total 4120.0 4120.0
PART B
DETAILS OF SALARY PAID AND ANY OTHER INCOME AND TAX DEDUCTED
1. Gross Salary
(a) Salary as per provisions contained in section 17(1)
360000.0
(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
360000.0
2. Less : Allowance to the extent exempt under section 10
Allowances Rs.
House Rent Allowance 0.0 0.0
Conveyance 0.0 0.0
Medical Bill 0.0 0.0
Leave Travel Allowance 0.0 0.0
Total 0.0

2. 3. Balance (1-2) 360000.0
4. Deductions
(a) Tax On Employment 0.0
(b) Total ESIC 0.0
5. Aggregate Of 4(a) and 4(b) 0.0
6.Income Chargeble Under the Head 'SALARIES'(3-5) 360000.0
7.Add:Any Other Income Reported By Employee 20000.0
8. Gross Total (6+7) 380000.0
9. Deductions under Chapter VI-A
(A) sections 80C Gross Deductible
Amount Amount
80C / 5 Years of Fixed Deposit in Schedule Bank 100000.0 100000.0
80C / 80CCF / Long Term Infrastructure Bonds-Centr 30000.0 20000.0
Note :1. aggregate amount deductible under section 80C
shall not exceed one lakh rupees.
2. aggregate amount deductible under the three sections ,
i.e., 80C, 80CCC and 80CCD, shall not exceed one lakh 120000.0
(B) other sections (e.g., 80E, 80G etc.) Under Chapter VIA 20000.0 20000.0
10. Aggregate of deductible amounts Rs. 140000.0
under Chapter VI-A
11. Total income (8—10) Rs. 240000.0
12. Tax on total 4000.0
13. Education Cess @ 3% on (tax at S. No.
120.0
12 plus surcharge at S. No. 13) Rs.
14. Surcharge @ 10%(above 1000000) 0.0
15. Tax payable (12+13+14) Rs. 4120.0
16. Relief under section 89 (attach details) Rs.
17.Tax Payable (15 - 16) 4120.0
Verification
I,abc,working in the capacity of,indiado hereby certify that the a sum ofRs. 4120.0 Rupees.... has been deducted at
source and paid to the credit of the CentralGovernment. I further certify that the information given above is true and
correct based on the books of account,documents and other available records.

3. Form 16
ANNEXURE-B
DETAILS OF TAX DEDUCTED AND DEPOSITED IN CENTRAL GOVERNMENT ACCOUNT THROUGH
CHALLAN
(The Employer to provide Payment wise details of tax deducted and deposited with respect to the employees)
Tax deposited in respect of the Challan Identification Number
employees (Rs.)
BSR Code Of the Date On Which Tax Challan Serial No
Bank Branch Deposited
1 343.0 7777777 03/05/1989 7777777
2 344.0 7777777 03/05/1989 7777777
3 343.0 7777777 03/05/1989 7777777
4 343.0 7777777 01/02/2014 7777777
5 343.0 7777777 01/02/2012 7777777
6 343.0 7777777 01/02/2012 7777777
7 343.0 7777777 01/02/2012 7777777
8 344.0 7777777 01/02/2013 7777777
9 343.0 7777777 01/02/2013 7777777
10 344.0 7777777 03/05/1989 7777777
11 343.0 7777777 03/05/1989 7777777
12 344.0 7777777 03/05/1989 7777777
Total 4120.0