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. UJGDPYA Last updated on 30-May-2025

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

AMERICAN EXPRESS (INDIA) PRIVATE LIMITED

METROPOLITAN -SAKET, 7TH FLOOR, OFFICE BLOCK,
JENNIFER JOHN
DELHI - 110017
73-B, LAL QUARTER, MADIPUR, PUNJABI BAGH, DELHI - 110026
Delhi
Delhi
+(91)124-6119506
PAYROLL.INDIA@AEXP.COM

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

AAACA8163F DELA04792E BRXPJ0966M

CIT (TDS) Assessment Year Period with the Employer

From To
The Commissioner of Income Tax (TDS)
Aayakar Bhawan, District Centre, 6th Floor Room no 610, Hall no. 2025-26 30-Sep-2024 31-Mar-2025
4 , Luxmi Nagar, Delhi - 110092

Annexure - I

Details of Salary Paid and any other income and tax deducted

A Whether opting out of taxation u/s 115BAC(1A)? No

1. Gross Salary Rs. Rs.

(a) Salary as per provisions contained in section 17(1) 441625.00

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 441625.00

(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

(f) Other special allowances under section 10(14) 0.00

Page 1 of 3
Certificate Number: UJGDPYA TAN of Employer: DELA04792E PAN of Employee: BRXPJ0966M Assessment Year: 2025-26

Amount of any other exemption under section 10

[Note: Break-up to be prepared by employer and issued to the
(g)
employee, where applicable, before furnishing of Part B to the
employee]

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

Total amount of exemption claimed under section 10

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

Total amount of salary received from current employer

3. 441625.00
[1(d)-2(i)]
4. Less: Deductions under section 16
(a) Standard deduction under section 16(ia) 75000.00

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

(c) Tax on employment under section 16(iii) 0.00

5. Total amount of deductions under section 16 [4(a)+4(b)+4(c)] 75000.00

6. Income chargeable under the head "Salaries" [(3+1(e)-5] 366625.00

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) 366625.00

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) 0.00 0.00
under section 80CCC
Deduction in respect of contribution by taxpayer to pension
(c) 0.00 0.00
scheme under section 80CCD (1)

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

Deductions in respect of amount paid/deposited to notified

(e) 0.00 0.00
pension scheme under section 80CCD (1B)
Deduction in respect of contribution by Employer to pension
(f) 0.00 0.00
scheme under section 80CCD (2)
Deduction in respect of health insurance premia under section
(g) 0.00 0.00
80D

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 Certificate Number: UJGDPYA TAN of Employer: DELA04792E PAN of Employee: BRXPJ0966M Assessment Year: 2025-26

Deduction in respect of interest on loan taken for higher

(h) 0.00 0.00
education under section 80E
Deduction in respect of contribution by the employee to Agnipath
(i) 0.00 0.00
Scheme under section 80CCH
Deduction in respect of contribution by the Central Government
(j) 0.00 0.00
to Agnipath Scheme under section 80CCH
Gross Qualifying Deductible
Amount Amount Amount
Total Deduction in respect of donations to certain funds,
(k) 0.00 0.00 0.00
charitable institutions, etc. under section 80G
Deduction in respect of interest on deposits in savings account
(l) 0.00 0.00 0.00
under section 80TTA

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

[Note: Break-up to be prepared by employer and issued to the
(m)
employee, where applicable , before furnishing of Part B to the
employee]

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

(n) 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(k)+10(l)+10(n)]

12. Total taxable income (9-11) 366625.00

13. Tax on total income 3331.00

14. Rebate under section 87A, if applicable 3331.00

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

Less: Tax deducted at source as per Form No. 12BAA submitted

19.
under provisions of section 192(2B)
0.00
Less: Tax collected at source as per Form No. 12BAA submitted
20.
under provisions of section 192(2B)

21. Net tax payable (17-18-19-20) 0.00

Verification
I, ANUJ MEHROTRA, son/daughter of KAILASH NARAIN MEHROTRA .Working in the capacity of AUTHORIZED
SIGNATORY (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 NEW DELHI (Signature of person responsible for deduction of tax)

Full
Date 31-May-2025 ANUJ MEHROTRA
Name:

Signature Not Verified

Digitally signed by Anuj
Mehrotra
Date: 2025.05.31 14:52:57
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