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

Certificate No. ADIRSXA Last updated on 15-Jun-2019

Name and address of the Employer Name and address of the Employee

KOTAK MAHINDRA LIFE INSURANCE COMPANY LIMITED

2ND FLOOR,, PLOT NO C-12,, G - BLOCK,
BKC, BANDRA EAST, MUMBAI - 400051 AVINESH KUMAR
Maharashtra C-730 BLOCK C, VIKAS PURI, NEW DELHI - 110018 Delhi
+(91)-66057426
CEDRIC.FERNANDES@KOTAK.COM

Employee Reference No.

PAN of the Employee
PAN of the Deductor TAN of the Deductor provided by the Employer
(If available)

AAACO3983B MUMO02128A BGEPK2165F

CIT (TDS) Assessment Year Period with the Employer

From To
The Commissioner of Income Tax (TDS)
Room No. 900A, 9th Floor, K.G. Mittal Ayurvedic Hospital 2019-20 01-Apr-2018 31-Mar-2019
Building, Charni Road , Mumbai - 400002

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

Q1 QTDQKFIA 171112.00 4983.00 4983.00

Q2 QTFBPZVE 151557.00 6172.00 6172.00
Q3 QTJPFLJA 151557.00 5996.00 5996.00
Q4 QTNHUJGG 154307.00 6151.00 6151.00
Total (Rs.) 628533.00 23302.00 23302.00
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*

1 802.00 0510075 07-05-2018 45724 F

2 2096.00 0510075 07-06-2018 33322 F
3 2085.00 0510075 06-07-2018 35980 F
4 2072.00 0510075 07-08-2018 52478 F

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This file is signed using Digital Signature.
 Certificate Number: ADIRSXA TAN of Employer: MUMO02128A PAN of Employee: BGEPK2165F Assessment Year: 2019-20

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*

5 2058.00 0510075 07-09-2018 26424 F

6 2042.00 0510075 05-10-2018 30161 F
7 2023.00 0510075 06-11-2018 42346 F
8 2001.00 0510075 07-12-2018 23709 F
9 1972.00 0510075 05-01-2019 20141 F
10 1935.00 0510075 07-02-2019 24876 F
11 2451.00 0510075 07-03-2019 29550 F
12 1765.00 0510075 25-04-2019 14359 F
Total (Rs.) 23302.00

Verification

I, CEDRIC DOMINIC FERNANDES, son / daughter of ALDYSIVS FERNANDES working in the capacity of SR EXECUTIVE V P (designation) do hereby certify that a
sum of Rs. 23302.00 [Rs. Twenty Three Thousand Three Hundred and Two Only (in words)] has been deducted and a sum of Rs. 23302.00 [Rs. Twenty Three
Thousand Three Hundred and Two 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.

Place MUMBAI

Date 18-Jun-2019 (Signature of person responsible for deduction of Tax)

Designation: SR EXECUTIVE V P Full Name:CEDRIC DOMINIC FERNANDES

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

Signature Not Verified

Signed by : CEDRIC DOMINIC FERNANDES
Date : 26-Jun-2019 10:35:18
Location : MUMBAI
Reason : FORM 16

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This file is signed using Digital Signature.