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 :		
2.	TAN		
3.	TDS Assessment Range of the employer :		
4.	Name, designation and PAN of employee :		
5.	Is the employee a director or a person with: 
substantial interest in the company (where the employer is a company)		
6.	Income under the head "Salaries" of the employee 
(other than from perquisites):		
7.	Financial year :		
8.	Valuation of Perquisites :		
S.No.	Nature of perquisites 
(see rule 3)	Value of perquisite as per rules (Rs.)	Amount, if any, recovered from the employee (Rs.)	Amount of perquisite chargeable to tax [Col.(3)- Col.(4)] (Rs.)	
(1)	(2)	(3)	(4)	(5)	
1.	Accommodation				
2.	Cars / Other automotive				
3.	Sweeper, gardener, 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 amenities				
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 under section 192(1)		
	(b) Tax paid by employer on behalf of the employee under section 192(1A)		
	(c) Total tax paid		
	(d) Date of payment into Government treasury		
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		Full Name		
Date		Designation