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

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1 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. SMOOPZJ Last updated on 01-Jun-2016 Name and address of the Employer CHOLA INSURANCE SERVICES PRIVATE LIMITED 2, DARE HOUSE, N.S.C.BOSE ROAD, PARRYS Tamilnadu +(91) PRABHUVP@CHOLAMS.MURUGAPPA.COM Name and address of the Employee SANTOSH ROY 8/1/A, JOY MITRA STREET, KOLKATA West Bengal PAN of the Deductor TAN of the Deductor PAN of the Employee Employee Reference No. provided by the Employer (If available) AAACB2345L CHEB02263C AJMPR2178K CIT (TDS) Assessment Year Period with the Employer The Commissioner of Income Tax (TDS) 7th Floor, New Block, Aayakar Bhawan, 121, M.G. Road, Chennai From 01-Apr-2015 To 31-Mar-2016 Summary of amount paid/credited and tax deducted at source thereon in respect of the employee Quarter(s) Receipt Numbers of original quarterly statements of TDS under sub-section (3) of Section 200 Amount paid/credited Amount of tax deducted Amount of tax deposited / remitted Q1 QRIKEUEC Q2 QRMJFVEA Q3 QRPXQBLB Q4 FXBQOBFB Total 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 ) Receipt Numbers of Form No. 24G Book Identification Number (BIN) DDO serial number in Form no. 24G Date of transfer voucher Status of matching with Form no. 24G Total 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 ) BSR Code of the Bank Branch Challan Identification Number (CIN) Date on which Tax deposited Challan Serial Number Status of matching with OLTAS* F F F F Page 1 of 2

2 Certificate Number: SMOOPZJ TAN of Employer: CHEB02263C PAN of Employee: AJMPR2178K Assessment Year: BSR Code of the Bank Branch Challan Identification Number (CIN) Date on which Tax deposited Challan Serial Number Status of matching with OLTAS* F F F F F F Total Verification I, MAHESH MADHUKAR WAIKAR, son / daughter of MADHUKAR DATTATRAYA WAIKAR working in the capacity of DIRECTOR (designation) do hereby certify that a sum of Rs [Rs. Five Thousand One Hundred and Seventy Nine Only (in words)] has been deducted and a sum of Rs [Rs. Five Thousand One Hundred and Seventy Nine 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 Date Designation: DIRECTOR CHENNAI 17-May-2016 (Signature of person responsible for deduction of Tax) 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 U P F O Unmatched Provisional Final Overbooked Deductors have not deposited taxes or have furnished incorrect particulars of tax payment. Final credit will be reflected only when payment 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 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 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 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

3 Emp Code : Certificate Number : SMOOPZJ FORM No - 16 [See rule 31 (1)(a) ] Certificate under section 203 of the Income - tax Act,1961 for Tax deducted at source on Salary Name and address of the Employer Chola Insurance Services Private Limited No 2,NSC Bose Road Dare House Chennai TAMIL NADU Name and Designation of the Employee SANTOSH ROY PAN of the Deductor TAN of the Deductor PAN of the Employee AAACB2345L CHEB02263C AJMPR2178K SENIOR PROCESS LEAD - CLAIMS ASSESSMENT CIT(TDS) Assessment Year Period The Commissioner of Income Tax (TDS) /04/ /03/2016 7th Floor, New Block, Aayakar Bhawan, 121, M G Road, Chennai Gross Salary PART B (Annexure) Details of salary paid and any other income and tax deducted From Rs Rs Rs (a) Salary as per provisions contained in Sec.17(1) 357, (b) Value of perquisites u/s 17(2) (as per Form No.12BA. wherever applicable) (c) Profits in lieu of salary under section 17(3) (as per Form No.12BA, wherever applicable) (d) Total 357, Less: Allowance to the extent exempt u/s 10 : Conveyance 18, , Balance (1-2) 338, Deductions : (a) Entertainment allowance 0.00 (b) Tax on employment 1, Aggregate of 4(a) and (b) 1, To 6. Income chargeable under the head 'salaries' (3-5) 336, Add/Less : Any other income reported by the employee Less : Interest on Housing Loan (Self Occupied) Gross total income (6 + 7) 336, Deductions under Chapter VI-A (A)Sections 80C,80CCC,80CCD Gross amount Qualifying amount Deductible amount (a) Section 80C Provident Fund (From Salary) 16, Total of above 16, , , Note : 1. Aggregate amount deductible U/S 80C,80CCC and 80CCD(1) shall not exceed one lakh and fifty thousand rupees. (B) Other sections (e.g 80E,80G,80TTA etc.) under Chapter VI-A 0.00 Page:3

4 Emp Code : Certificate Number : SMOOPZJ 10. Aggregate of deductible amount under Chapter VI-A 16, Total Income (8-10) 320, Tax on total income before section 87A 7, TAX Credit Under Section 87A 2, Tax on Total Income 5, Surcharge Education 3% (on tax computed at S.No.14+15) Tax Payable ( ) 5, Less: Relief under section 89 (attach details) Tax payable (17-18) 5, Verification I, MAHESH MADHUKAR WAIKAR, Son / Daughter of MADHUKAR DATTATRAYA WAIKAR working in the capacity of DIRECTOR 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: Chennai Date: Signature of the person responsible for deduction of tax Designation :DIRECTOR Page:4

5 Emp Code : Certificate Number :SMOOPZJ FORM NO.12BA [See rule 26A(2)(b)] Statement showing particulars of perquisites, other fringe benefits or amenities and profits in lieu of salary with value thereof 1. Name and address of employer: Chola Insurance Services Private Limited No 2,NSC Bose Road Dare House Chennai TAMIL NADU 2. TAN: CHEB02263C 3. TDS Assessment Range of the employer: The Commissioner of Income Tax (TDS) 7th Floor, New Block, Aayakar Bhawan, 121, M G Road, Chennai Name, designation and PAN of the employee: SANTOSH ROY 5. Is the employee a director or a person with : SENIOR PROCESS LEAD - CLAIMS ASSESSMENT AJMPR2178K substantial interest in the company No (where the employer is a company) 6. Income under the head '' Salaries '' of the employee : (other than from perquisites) 357, Financial Year : Valuation of Perquisites: 0.00 S.No Nature of perquisites (see rule 3) Value of perquisite Amount if any Amount of perquisite as per rules recovered from the chargeable to tax employee Col (3) - Col(4) (1) (2) (3) (4) (5) 1. Accomodation Cars/Other automotive Sweeper,gardener,watchman or personal attendent 4. Gas,electricity,water Interest free or concessional loans Holiday expenses Free or concessional travel Free meals Free education Gifts,vouchers,etc Credit card expenses Club expenses Use of movable assets by employees Transfer of assets to employees Value of any other benfit/ amenity/service/privilege Stock options(non-qualified options) Other benfits or amenities Total value of perquisites Total value of Profits in lieu of salary salary as per section 17(3) Details of Tax,- (a) Tax deducted from salary of the employee under section 192(1) 0.00 (b) Tax paid by employer on behalf of employee under section 192(1A) (c)total tax paid 0.00 (d)date of payment into Government treasury Declaration by Employer NIL As per form 16 enclosed I, MAHESH MADHUKAR WAIKAR Son / Daughter of MADHUKAR DATTATRAYA WAIKAR working as DIRECTOR do hereby declare on behalf of Chola Insurance Services Private Limited that the information given above is based on the books of account, documents and other relevant records or information available with us and the details of value of each such perquisite are in accordance with section 17 and rules framed thereunder and that such information is true and correct. Place: Chennai Date: Signature of the person responsible for deduction of tax. Designation:DIRECTOR Page:5