Prepare Salary Satement and Form 16

Name

Designation Asst. Teacher Head Teacher Male Female

Circle

District Select ALIPURDUARBANKURABIRBHUMCOOCHBEHARDAKSHIN DINAJPURDARJILINGHOOGHLYHOWRAHJALPAIGURIJHARGRAMKALIMPONGKOLKATAMALDAHMURSHIDABADNADIANORTH 24 PARGANASPASCHIM BARDHAMANPASCHIM MEDINIPURPURBA BARDHAMANPURBA MEDINIPURPURULIYASILIGURISOUTH 24 PARGANASUTTAR DINAJPUR

PAN No.

Name of School

Basic Pay in March 2024

GPF (Leave blank if normal)

If you Received 18 Years benefit, then
enter Current Basic (else leave blank)

P.Tax Exmpted? No Yes

Receiving Medical Allowence Yes No

10/20 years benefit No Yes

GSLI

Arrears (If any else leave blank)

Total Income from other sources

TAN No. of DPSC (if known)