The document is an income tax form (Form 16) that provides details of tax deducted at source from an individual's salary. It includes: - Identification information for both the deductee (employee) and deductor (employer) - Details of the salary paid and taxes deducted on a quarterly basis - A breakdown of the salary, deductions, total income and tax amount payable - A certification from the deducting officer that taxes have been correctly deducted and paid to the government.

1. FORM NO.16A
[See rule 31(1)(b)]
Certificate under section 203 of the Income-tax Act, 1961
for Tax deducted at source
TDS Certificate
Financial year
number#
Whether Original / Duplicate / Amended If Amended give Previous TDS Certificate number
TAN of Deductor Name of the Deductor
PAN of Deductee Name of the Deductee
Whether PAN uploaded
TDS Unique Transaction
was validated by
Number (UTN) as provided by Gross Amount Paid TDS
Income Tax
Income Tax Department
Department? (Y/N)
Gross TDS amount
Total TDS amount where PAN was found valid by Income Tax Department
I _____________________________________, son/daughter of ___________________________________ working in
the capacity of ______________________________________ (designation) do hereby certify that a sum of Rs.
____________________________ [Rupees _____________________________________
________________________________________________________________________________ (in words)] has been
deducted at source and paid to the credit of the Central Government. I further certify that the information given
above is true and correct based on the books of accounts, documents and other available records.
Place
Date Signature of person responsible for deduction of tax
Designation Full Name
# TDS certificate number is an internal reference number to be given by the Deductor (optional)
www.taxguru.in

2. FORM NO.16
[See rule 31(1)(a)]
Certificate under section 203 of the Income-tax Act, 1961 for Tax deducted at source on Salary
TDS Certificate
Financial year 2009-2010 36/2010
number#
If Amended give Previous TDS Certificate
Whether Original / Duplicate / Amended N/A
number
Deputy Conservator of Forest,
Forest and Wildlife Department
TAN of Deductor DELG08919G Name of Deductor
GNCT of Delhi,Tugalkabad
Shooting Range, New Delhi
SHEESH RAM S/O RAM
PAN of Deductee CLEPS4130G Name of Deductee
SWAROOP
Whether PAN uploaded
TDS Unique Transaction Number (UTN) was validated by Gross Amount
TDS/TCS Amount
as provided by Income Tax Department Income Tax Paid / Collected
Department? (Y/N)
Quarter 1 011420100118210
Quarter 2 011420100118221
Quarter 3 011420200100993
Quarter 4 011420200100982
Gross amount of TDS / TCS
Details of Salary paid and any other income and tax deducted
1 Gross Salary
(a) Salary as per provisions contained in sec.17(1) Rs 220347
Value of perquisites u/s 17(2) (as per Form No.12BB,
(b) Rs 000
wherever applicable)
Profits in lieu of salary under section 17(3)(as per
(c) Rs
Form No.12BB, wherever applicable)
(d) Total Rs 220347
2 Less: Allowance to the extent exempt u/s 10 Rs 000
Rs 000
Rs 000 Rs
3 Balance(1-2) Rs 220347
4 Deductions :
(a) Standard deduction Rs. 0
(b) Entertainment allowance Rs. 0
(c) Tax on employment Rs. 0
5 Aggregate of 4(a) to (c) Rs 000
6 Income chargeable under the head 'salaries' (3-5) Rs 220347

3. 7 Add: Any other income reported by the employee Rs 000
Rs
Rs 0 Rs 0
8 Gross total income (6+7) Rs 220347
9 Deductions under Chapter VIA
Qualifying Deductible
Gross Amount
Amount Amount
(a) GPF Rs 36000 Rs 36000 Rs 36000
(b) CGEIS Rs 180 Rs 180 Rs 180
(c) Rs Rs Rs
(d) Rs Rs Rs Rs 36180
10 Aggregate of deductible amount under Chapter VIA Rs 36180
11 Total Income (8-10) Rs 184167
12 Tax on total income Rs 2417
13 Rebate and relief under Chapter VIII
I. Under section 88 (please specify)
Qualifying Tax rebate/
Gross Amount
Amount relief
(a) Rs Rs 0
(b) Rs Rs 0
(c) Rs Rs 0
(d) Rs Rs 0
(e) Rs Rs 0
(f) Total [(a)
Rs Rs 0
to (e)]
II (a) Under section 88B Rs 0
(b) Under section 88C Rs 0
III Under section 89 (attach details) Rs 0
Aggregate of tax rebates and relief at 13 above [I(f) +
14 Rs 0
II(a)+ II(b) + III]
15 Tax payable (12-14) and surcharge thereon Rs 2490
16 Less: Tax deducted at source Rs 0
17 Tax payable/refundable (15-16) Rs 2490
I PRABHAT TYAGI, son/daughter of SH P N TYAGI working in the capacity of D. D. O. (designation) do hereby certify
that a sum of Rs.2490/-[Rupees TWO THOUSAND FOUR HUNDRED NINETY ONLY (in words)] has been deducted at
source and paid to the credit of the Central Government. I further certify that the information given above is true and
correct based on the books of accounts, documents and other available records.
Place NEW DELHI
Date 29/04/2010 Signature of person responsible for deduction of tax
Designation: DDO Full Name : PRABHAT TYAGI