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 on salary paid to an employee under section 192 or pension/interest income
of specified senior citizen under section 194P

Certificate No. UVLZMRA Last updated on 08-May-2023

Name and address of the Employer/Specified Bank Name and address of the Employee/Specified senior citizen

INNOVATION SYSTEMS
85,, SGR Dental College Rd, Kasavanahalli Village, JAYA RAJA REDDY KILLIM
Marathahalli, Bengaluru, - 560037 DO NO 40-9-6, RAJAHMUNDRY, MANGALAVARAPU PETA,
Karnataka OPPISITE GOVT BOYS HIGH S, EAST GODAVARI - 533101 Andhra
Pradesh
[email protected]

PAN of the Employee Reference No. provided by the

PAN of the Deductor TAN of the Deductor Employee/Specified senior Employer/Pension Payment order no. provided
citizen by the Employer (If available)

AAJFI6757P BLRI12389G EPRPK5187N

CIT (TDS) Assessment Year Period with the Employer

From To
The Commissioner of Income Tax (TDS)
Room No. 59, H.M.T. Bhawan, 4th Floor, Bellary Road , 2022-23 01-Apr-2021 31-Mar-2022
Ganganagar, Bangalore - 560032

Summary of amount paid/credited and tax deducted at source thereon in respect of the employee

Receipt Numbers of original

Amount of tax deposited / remitted
quarterly statements of TDS Amount of tax deducted
Quarter(s) Amount paid/credited (Rs.)
under sub-section (3) of (Rs.)
Section 200

Q4 QVGNEVIF 500000.00 0.00 0.00

Total (Rs.) 500000.00 0.00 0.00
I. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH BOOK ADJUSTMENT
(The deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)

Book Identification Number (BIN)

Tax Deposited in respect of the
Sl. No. deductee Date of transfer voucher Status of matching
Receipt Numbers of Form DDO serial number in Form no.
(Rs.) (dd/mm/yyyy) with Form no. 24G
No. 24G 24G

Total (Rs.)
II. DETAILS OF TAX DEDUCTED AND DEPOSITED IN THE CENTRAL GOVERNMENT ACCOUNT THROUGH CHALLAN
(The deductor to provide payment wise details of tax deducted and deposited with respect to the deductee)

Challan Identification Number (CIN)

Tax Deposited in respect of the
Sl. No. deductee
(Rs.) BSR Code of the Bank Date on which Tax deposited Challan Serial Number Status of matching with
Branch (dd/mm/yyyy) OLTAS*

1 0.00 - 16-01-2023 - F
Total (Rs.) 0.00

Verification

I, VENKATESAN HARISH, son / daughter of VENKATESAN working in the capacity of ACCOUNTS INCHARGE (designation) do hereby certify that a sum of Rs. 0.00
[Rs. Zero Only (in words)] has been deducted and a sum of Rs. 0.00 [Rs. Zero Only] has been 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.

Page 1 of 2
 Certificate Number: UVLZMRA TAN of Employer: BLRI12389G PAN of Employee: EPRPK5187N Assessment Year: 2022-23

Place Bengaluru,

Date 09-May-2023 (Signature of person responsible for deduction of Tax)

Designation: ACCOUNTS INCHARGE Full Name:VENKATESAN HARISH

Notes:
1. Part B (Annexure) of the certificate in Form No.16 shall be issued by the employer.
2. If an assessee is employed under one employer during the year, Part 'A' of the certificate in Form No.16 issued for the quarter ending on 31st March of the financial year shall contain the details
of tax deducted and deposited for all the quarters of the financial year.
3. If an assessee is employed under more than one employer during the year, each of the employers shall issue Part A of the certificate in Form No.16 pertaining to the period for which such
assessee was employed with each of the employers. Part B (Annexure) of the certificate in Form No. 16 may be issued by each of the employers or the last employer at the option of the assessee.
4. To update PAN details in Income Tax Department database, apply for 'PAN change request' through NSDL or UTITSL.

Legend used in Form 16

* Status of matching with OLTAS

Legend Description Definition
Deductors have not deposited taxes or have furnished incorrect particulars of tax payment. Final credit will be reflected only when payment
U Unmatched
details in bank match with details of deposit in TDS / TCS statement
Provisional tax credit is effected only for TDS / TCS Statements filed by Government deductors."P" status will be changed to Final (F) on
P Provisional
verification of payment details submitted by Pay and Accounts Officer (PAO)
In case of non-government deductors, payment details of TDS / TCS deposited in bank by deductor have matched with the payment details
F Final mentioned in the TDS / TCS statement filed by the deductors. In case of government deductors, details of TDS / TCS booked in Government
account have been verified by Pay & Accounts Officer (PAO)
Payment details of TDS / TCS deposited in bank by deductor have matched with details mentioned in the TDS / TCS statement but the
O Overbooked amount is over claimed in the statement. Final (F) credit will be reflected only when deductor reduces claimed amount in the statement or
makes new payment for excess amount claimed in the statement

Page 2 of 2
 FORM NO. 16
PART B
Certificate under section 203 of the Income-tax Act, 1961 for tax deducted at source on salary paid to an employee under section 192 or pension/interest income
of specified senior citizen under section 194P

Certificate No. UVLZMRA Last updated on 08-May-2023

Name and address of the Employer/Specified Bank Name and address of the Employee/Specified senior citizen

INNOVATION SYSTEMS
85,, SGR Dental College Rd, Kasavanahalli Village, JAYA RAJA REDDY KILLIM
Marathahalli, Bengaluru, - 560037 DO NO 40-9-6, RAJAHMUNDRY, MANGALAVARAPU PETA,
Karnataka OPPISITE GOVT BOYS HIGH S, EAST GODAVARI - 533101 Andhra
Pradesh
[email protected]

PAN of the Deductor TAN of the Deductor PAN of the Employee/Specified senior citizen

AAJFI6757P BLRI12389G EPRPK5187N

CIT (TDS) Assessment Year Period with the Employer

From To
The Commissioner of Income Tax (TDS)
Room No. 59, H.M.T. Bhawan, 4th Floor, Bellary Road , 2022-23 01-Apr-2021 31-Mar-2022
Ganganagar, Bangalore - 560032

Annexure - I

Details of Salary Paid and any other income and tax deducted

Whether opting for taxation u/s 115BAC No

1. Gross Salary Rs. Rs.

(a) Salary as per provisions contained in section 17(1) 500000.00

Value of perquisites under section 17(2) (as per Form No. 12BA,
(b) 0.00
wherever applicable)
Profits in lieu of salary under section 17(3) (as per Form No.
(c) 0.00
12BA, wherever applicable)
(d) Total 500000.00

(e) Reported total amount of salary received from other employer(s) 0.00

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

(a) Travel concession or assistance under section 10(5) 0.00

(b) Death-cum-retirement gratuity under section 10(10) 0.00

(c) Commuted value of pension under section 10(10A) 0.00

Cash equivalent of leave salary encashment under section 10

(d) 0.00
(10AA)

(e) House rent allowance under section 10(13A) 0.00

Page 1 of 4
Certificate Number: UVLZMRA TAN of Employer: BLRI12389G PAN of Employee: EPRPK5187N Assessment Year: 2022-23

Amount of any other exemption under section 10

(f) [Note: Break-up to be filled and signed by employer in the table
provide at the bottom of this form]

(g) Total amount of any other exemption under section 10 0.00

Total amount of exemption claimed under section 10

(h) 0.00
[2(a)+2(b)+2(c)+2(d)+2(e)+2(g)]

Total amount of salary received from current employer

3. 500000.00
[1(d)-2(h)]
4. Less: Deductions under section 16
(a) Standard deduction under section 16(ia) 50000.00

(b) Entertainment allowance under section 16(ii) 0.00

(c) Tax on employment under section 16(iii) 2400.00

5. Total amount of deductions under section 16 [4(a)+4(b)+4(c)] 52400.00

6. Income chargeable under the head "Salaries" [(3+1(e)-5] 447600.00

7. Add: Any other income reported by the employee under as per section 192 (2B)

Income (or admissible loss) from house property reported by

(a) 0.00
employee offered for TDS

(b) Income under the head Other Sources offered for TDS 0.00

Total amount of other income reported by the employee

8. 0.00
[7(a)+7(b)]
9. Gross total income (6+8) 447600.00

10. Deductions under Chapter VI-A Gross Amount Deductible Amount

Deduction in respect of life insurance premia, contributions to

(a) 0.00 0.00
provident fund etc. under section 80C

Deduction in respect of contribution to certain pension funds

(b) under section 80CCC 0.00 0.00

Deduction in respect of contribution by taxpayer to pension

(c) scheme under section 80CCD (1) 0.00 0.00

(d) Total deduction under section 80C, 80CCC and 80CCD(1) 0.00 0.00

Deductions in respect of amount paid/deposited to notified

pension scheme under section 80CCD (1B)
(e) 0.00 0.00

Page 2 of 4
 Certificate Number: UVLZMRA TAN of Employer: BLRI12389G PAN of Employee: EPRPK5187N Assessment Year: 2022-23

Deduction in respect of contribution by Employer to pension

(f) scheme under section 80CCD (2) 0.00 0.00

Deduction in respect of health insurance premia under section

(g) 0.00 0.00
80D

Deduction in respect of interest on loan taken for higher

(h) education under section 80E 0.00 0.00

Gross Qualifying Deductible

Amount Amount Amount
Total Deduction in respect of donations to certain funds,
(i) 0.00 0.00 0.00
charitable institutions, etc. under section 80G
Deduction in respect of interest on deposits in savings account
(j) 0.00 0.00 0.00
under section 80TTA

Amount Deductible under any other provision (s) of Chapter VI-A

(k) [Note: Break-up to be filled and signed by employer in the table
provide at the bottom of this form]

Total of amount deductible under any other provision(s) of

(l) 0.00 0.00 0.00
Chapter VI-A

Aggregate of deductible amount under Chapter VI-A

11. 0.00
[10(d)+10(e)+10(f)+10(g)+10(h)+10(i)+10(j)+10(l)]

12. Total taxable income (9-11) 447600.00

13. Tax on total income 9880.00

14. Rebate under section 87A, if applicable 9880.00

15. Surcharge, wherever applicable 0.00

16. Health and education cess 0.00

17. Tax payable (13+15+16-14) 0.00

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

19. Net tax payable (17-18) 0.00

Verification
I, VENKATESAN HARISH, son/daughter of VENKATESAN .Working in the capacity of ACCOUNTS INCHARGE (Designation)
do hereby certify that the information given above is true, complete and correct and is based on the books of account, documents, TDS
statements, and other available records.

Place Bengaluru, (Signature of person responsible for deduction of tax)

Full
Date 09-May-2023 VENKATESAN HARISH
Name:

Page 3 of 4
 Certificate Number: UVLZMRA TAN of Employer: BLRI12389G PAN of Employee: EPRPK5187N Assessment Year: 2022-23

2. (f) Break up for ‘Amount of any other exemption under section 10’ to be filled in the table below
Particular's of Amount for any other
Sl. exemption under section 10 Gross Amount Qualifying Amount Deductible Amount
No.
Rs. Rs. Rs. Rs.
1.
2..
3.
4.
5.
6.

10(k). Break up for ‘Amount deductible under any other provision(s) of Chapter VIA ‘to be filled in the table below
Particular's of Amount deductible under
Sl. any other provision(s) of Chapter VIA Gross Amount Qualifying Amount Deductible Amount
No.
Rs. Rs. Rs. Rs.
1.
2.
3.
4.
5.
6.

Bengaluru, (Signature of person responsible for deduction of

Place
tax)
Full
Date 09-May-2023 VENKATESAN HARISH
Name:

Signature Not Verified

Page 4 of 4
Digitally signed by HARISH
VENKATESAN
Date: 2023.05.09 11:37:22
+05:30