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 employer :  
___________________________________________________________________________ 
2) TAN : _________________________________________________________________ 
3)TDS Assessment Range of the employer:  
_____________________________________________________ 
4) Name, designation and PAN of employer  
________________________________________________________________ 
5) Is the employee a director or a person with substantial interest in the company 
(where ihe employer is a 
company):_____________________________________________________________________ 
6) Income under the head "Salaries" of the employee 
(other than from prequisites)  
___________________________________________________________________________ 
7)Financial Year:____________________________ 
8)Valuation of Prequisities: 
S.No  Nature of perquisite   
 Value of  
perquisite as per  
rules   
(Rs.) 
 Amount, if any  
paid by 
employee  
(Rs.) 
 Amount of  
taxable 
perquisite  
(Rs.) 
(see rule 3) 
1.  Accommodation        
2 .  Cars/Other automotive        
3.  Sweeper, gardeners, watchman or 
      
personal attendant 
4.  Gas, electricity, water       
5.  Interest free or concessional loans       
6.  Holiday expenses        
7.  Free or concessional travel       
8.  Free meals 
      
9 .  Free Education       

10.  Gifts, vouchers etc.       
11.  Credit card expenses       
12.   Club expenses       
13.   Use of movable assets by employees       
14.  Transfer of assets to employees       
15 .  Value of any other 
      
benefit/amenity/service/privilege 
16.   Stock options (non qualified options)       
17.  Other benefits or ameneties        
18.  Total value of perquisites       
19.  Total value of profits in lieu of salary 
      
as per 17(3) 
9) Details of tax, - 
(a) Tax deducted from salary of the employee u/s 192(1) 
(b)Tax paid by employee on behalf of the employee u/s 192(1A)  
(c)Total tax paid 
(d)Date of payment into Government tresury 
  DECLARATION BY EMPLOYER 
I ……………………………………….……. S/o ………………………………………. working as………………..... 
……………………………(designation) do hereby declare on behalf of ……… …….……..…..............(name of 
the employer) 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. 

           Signature of the person responsible  for deduction of tax 
Place… 
Date…  
 Full Name …………………… 
Designation ………………….