PllForm12bb

FORM NO. 124

Please Select Tax Regime
FORM NO. 124
(See Rule 205)
Part A: Details of the employee
1. Name of the employee:
2. Address:
3. Permanent Account Number of the employee:
4. Email ID:
5. Contact Number:
6. Tax Year
Part B: Details of claims and evidence thereof
Sl No. Nature of claim Amount (Rs.) Approved Amount Remarks Employee Remarks Final Approved Amount Final Remarks
1 House Rent Allowance:  
  (i) Name of the landlord
  (ii) Address of the landlord
  (iii) Permanent Account Number of the landlord
  (iv) Aadhar Number of landlord
  (v) Relationship with the landlord, if any
  (vi) Rent paid to the landlord per month
  Note: Permanent Account Number and copy of PAN shall be furnished if the aggregate rent paid during the previous year exceeds one Lakh rupees  
2 Leave travel concessions or assistance
3 Deduction of interest on Home Loan:  
  (i) Interest payable/paid to the lender
  (ii) Name of the lender
  (iii) Address of the lender
  (iv) Permanent Account Number of the lender
4 Deduction under Chapter VIII-A and B of the Act  
  Section 123 -LIC/PPF/Housing Loan/Tution Fee etc. up to Rs. 1,50,000/-
  Section 124(3)- NPS up to Rs. 50000/-
  Section 126 - Medical Insurance & Expenses on Preventive Health Check-up
  Section 127 - Expenses of Rehabilitation of Handicapped dependent
  Section 128 - Medical Expenses for Self or Dependent (For certain specified diseases only)
  Section 129 - Repayment of Interest on Loan for Higher Education
  Section 130 - House Loan Interest Deduction over & above 2 Lacs(Low Cost Housing Loans)
  Section 131 - House Loan Interest Deduction over & above 2 Lacs(Low Cost Housing Loans)
  Section 154 - Deduction for Disabled Individual
B Telephone /Mobile/Internet Bills Amount
Declaration
I, , having Permanent Account Number do hereby certify that the information given above is complete and correct
Place:
Date: 17/09/2026 Full Name:
Designation: Father name:


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