EMP ID : P101085

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 from income chargeable under the head '
Salaries'
Name and address of the employer Name and designation of the employee
MAX BUPA HEALTH INSURANCE COMPANY LIMITED MR.NITIN KUMAR CHOUDHARY
Max House MANAGER - GROUP BUSINESS (HEALTH & WELLNESS)
1 Dr Jha Marg, Okhla,
New Delhi - 110020

PAN No. of the Deductor TAN No. of the Deductor PAN No. of the Employee
AAFCM7916H DELM16656D AJIPC4503B
CIT(TDS) Assessment Year Period
Address: The Commissioner of Income Tax (TDS)
Aayakar Bhawan District Centre, FROM TO
6th Floor Room no 610 Hall no. 4, 2013-14
Luxmi Nagar

City: Delhi Pin Code: 110092 01-Apr-2012 31-Mar-2013

Summary of tax deducted at source

Quarter Receipt Numbers of original Amount of tax deducted Amount of tax

statements of TDS under sub-section in respect of the employee deposited/remitted in respect of
(3) of section 200. the employee
Quarter 1 IDVXXDDA 7175.00 7175.00

Quarter 2 JWIXDPBE 6898.00 6898.00

Quarter 3 IDVXBGLD 6900.00 6900.00

Quarter 4 MOHXBKSB 45019.00 45019.00

Total 65992.00 65992.00

PART B

Details of Salary paid and any other income and tax deducted

1. Gross salary (Rs.) (Rs.) (Rs.)

a) Salary as per provisions contained in section 17(1) 870728.26
b) Value of perquisites under section 17(2) (as per Form no.
12BA, wherever applicable) 0.00
c) Profits in lieu of salary under section 17(3) (as per Form No.
12BA, wherever applicable) 0.00
d) Total 870728.26

2. Less: Allowance to the extent exempt under section 10

House Rent Allowance 101215.90
Transport Allowance 9600.00
110815.90

3. Balance (1-2) 759912.36

4. Deductions:
a) Entertainment Allowance 0.00
b) Tax on Employment 0.00

5. Aggregate of 4 (a) and (b) 0.00

6. Income chargeable under the head 'Salaries' (3-5) 759912.36

7. Add: Any other income reported by the employee

0.00

8. Gross Total Income (6+7) 759912.36

9. Deductions Under Chapter VI-A

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 EMP ID : P101085

Gross Amount Deductible Amount

(A) Sections 80C, 80CCC and 80CCD
(a) Section 80C
i) Employee Contribution to Provident 27564.00
Fund
ii) Life Insurance Premium 124000.00
Aggregate of 80C 151564.00 89564.00

Aggregate of 80C, 80CCC & 80CCD 151564.00 89564.00

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, 80CCCC and 80CCD shall not
exceed one lakh rupees.
Gross Amount Qualifying Amount Deductible Amount
(B) Other Sections (for e.g., 80E, 80G etc.) 0.00 0.00 0.00
under Chapter VIA

10. Aggregate of deductible amounts under Chapter VI-A 89564.00

11. Total Income (8-10) 670350.00

12. Tax On Total Income 64070.00

13. Education Cess @ 3% (on tax computed at S.No. 12) 1922.00

14. Tax Payable (12+13) 65992.00

15. Less: Relief under section 89 (attach details) 0.00

16. Tax Payable (14 -15) 65992.00

Verification

I, VIKAS RASTOGI son/daughter of Shri KC RASTOGI working in the capacity of Head - Financial reporting & Controls do hereby certify that a sum of Rs.
65992.00 [Rupees sixty five thousand nine hundred ninety two and zero paise only] has been deducted and 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 10-Jun-2013 Signature of the person responsible for deduction of tax

Designation: Head - Financial reporting & Controls Full Name: VIKAS RASTOGI

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 EMP ID : P101085

ANNEXURE-B
DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH
CHALLAN
(The Employer to provide payment wise details of tax deducted and deposited with respect to the employee)

S.NO Tax Deposited in Challan Identification Number (CIN)

respect of the
BSR Code of the Date on which tax Challan Serial
employee (Rs.)
Bank deposited Number
Branch (dd/mm/yyyy)
1 2510.00 6360218 05/05/2012 33810

2 2366.00 6360218 06/06/2012 40402

3 2299.00 6360218 06/07/2012 32412

4 2299.00 6360218 04/08/2012 34397

5 2301.00 6360218 05/09/2012 37726

6 2298.00 6360218 03/10/2012 33050

7 2301.00 6360218 03/11/2012 31453

8 2298.00 6360218 04/12/2012 34468

9 2301.00 6360218 05/01/2013 42155

10 2298.00 6360218 04/02/2013 35954

11 8740.00 6360218 02/03/2013 31338

12 33981.00 6360218 03/04/2013 33362

Total 65992.00

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 EMP ID : P101085

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 : MAX BUPA HEALTH INSURANCE COMPANY LIMITED
Max House
1 Dr Jha Marg, Okhla,
New Delhi - 110020
2. TAN : DELM16656D
3. TDS Assessment Range of the employer : DC/ AC CIR6 (1)/ DEL/C/036/01
4. Name, designation and PAN of employee : MR.NITIN KUMAR CHOUDHARY
MANAGER - GROUP BUSINESS (HEALTH & WELLNESS)
AJIPC4503B
5. Is the employee a director or a person with substantial : No
interest in the company (where the employer is a company)
6. Income under the head "Salaries" of the employee : 759912.36
(Other than from perquisites)
7. Financial Year : 2012-13
8. Valuation of Perquisites :

S.No Nature of perquisite (see rule 3) Value of perquisite Amount, if any Amount of perquisite
as per rules (Rs.) recovered from chargeable to tax
employee (Rs.) Col (3) - Col (4) (Rs.)
1 Accommodation 0.00 0.00 0.00
2 Cars/Other Automotive 0.00 0.00 0.00
3 Sweeper, Gardeners, Watchman Or Personal
0.00 0.00 0.00
Attendant
4 Gas, Electricity, Water 0.00 0.00 0.00
5 Interest Free Or Concessional Loans 0.00 0.00 0.00
6 Holiday Expenses 0.00 0.00 0.00
7 Free Or Concessional Travel 0.00 0.00 0.00
8 Free Meals 0.00 0.00 0.00
9 Free Education 0.00 0.00 0.00
10 Gifts, Vouchers Etc. 0.00 0.00 0.00
11 Credit Card Expenses 0.00 0.00 0.00
12 Club Expenses 0.00 0.00 0.00
13 Use Of Movable Assets By Employees 0.00 0.00 0.00
14 Transfer Of Assets To Employees 0.00 0.00 0.00
15 Value Of Any Other Benefit/Amenity/Service/Privilege
0.00 0.00 0.00
(Employer Paid tax)
16 Stock Options (Non Qualified Options) 0.00 0.00 0.00
17 Other Benefits Or Amenities 0.00 0.00 0.00
18 Total Value Of Perquisites 0.00 0.00 0.00
19 Total Value Of Profits In Lieu Of Salary as per 17(3) 0.00 0.00
9. Details of Tax
a) Tax deducted from salary of the employee u/s 192(1) :65992.00
b) Tax paid by employer on behalf of the employee u/s 192(1A) :0.00
c) Total tax paid :65992.00
d) Date of payment into Government treasury :Various Dates as mentioned under 'Details of tax deducted and
deposited into Central Government Account' section of
Form 16
DECLARATION BY EMPLOYER
I, VIKAS RASTOGI, son/daughter of Shri KC RASTOGI working as Head - Financial reporting & Controls do hereby declare on behalf of
MAX BUPA HEALTH INSURANCE COMPANY LIMITED 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 there under and that such information is true and correct.
Place : New Delhi Signature of the person responsible for deduction of tax

Date : 10-Jun-2013 Full Name : VIKAS RASTOGI

Designation : Head - Financial reporting & Controls

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