OPTUM GLOBAL SOLUTIONS (INDIA) PRIVATE

LIMITED

Form 16
Assessment Year 2019-20
Employee Name T E HARISH KUMAR
Employee PAN BJAPK1447H
Employee Code 001210971
Employee Designation TECH SUPPORT ANALYST
Period With The Employer From : April 1, 2018 To : March 31, 2019

Note on Digital Signature:

This Form-16 document has been digitally signed with a Digital Signature Certificate as
allowed under section 119 of the Income-Tax Act, 1961. Refer Circular No.2/2007, Dated
21-May-2007 for details.

Affixing of Digital Signature means that a secure cryptographic procedure has been
applied to the entire contents of this document and a unique digital signature (equivalent to
affixing of hand written signature) has been embedded in this document.To view and
validate the digital signature details, please click on the digital signature affixed below.

Signature Details:
Signature Not Verified
CHITTARANJAN KUMAR
Security Reason
HYDERABAD
05.07.2019 11:06

Digitally Signed by : CHITTARANJAN KUMAR

 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. SPHCZMA Last updated on 14-Jun-2019

Name and address of the Employer Name and address of the Employee
OPTUM GLOBAL SOLUTIONS (INDIA) PRIVATE LIMITED
5TH 6TH & 7TH, SUNDEW PROPERTIES SEZ, APIIC
LAYOUT,SURVEY NO.64, TAMTAM EDIGA HARISH KUMAR
HITECH CITY, MADHAPUR, HYDERABAD, TELANGANA - 500081 7 -4-423/A, KALYAN NAGAR BALANGAR, HYDERABAD,
Telangana HYDERABAD - 500042 Telangana
+(91)40-69991898
CHITTARANJAN_KUMAR@UHG.COM
Employee Reference No.
PAN of the Employee
PAN of the Deductor TAN of the Deductor provided by the Employer
(If available)

AAACQ2188G HYDQ00152F BJAPK1447H

CIT (TDS) Assessment Year Period with the Employer

From To
The Commissioner of Income Tax (TDS)
Room No. 411, Income Tax Towers, 10-2-3 A.C. Guard , 2019-20 01-Apr-2018 31-Mar-2019
Hyderabad - 500004

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 QTCHZDUB 94310.00 0.00 0.00

Q2 QTGSCPBA 115315.00 0.00 0.00
Q3 QTJEVNYB 109241.00 0.00 0.00
Q4 QTOKAUEG 138080.00 2130.00 2130.00
Total (Rs.) 456946.00 2130.00 2130.00
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 0.00 - 05-05-2018 - F
2 0.00 - 06-06-2018 - F
3 0.00 - 05-07-2018 - F
4 0.00 - 07-08-2018 - F

Page 1 of 2
 Certificate Number: SPHCZMA TAN of Employer: HYDQ00152F PAN of Employee: BJAPK1447H 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 0.00 - 07-09-2018 - F
6 0.00 - 06-10-2018 - F
7 0.00 - 03-11-2018 - F
8 0.00 - 06-12-2018 - F
9 0.00 - 05-01-2019 - F
10 0.00 - 07-02-2019 - F
11 1760.00 6910333 07-03-2019 31455 F
12 370.00 6910333 26-04-2019 17626 F
Total (Rs.) 2130.00

Verification

I, CHITTARANJAN KUMAR, son / daughter of SHIV SHANKAR SINGH working in the capacity of DIR HR OPS PAYROLL (designation) do hereby certify that a sum of
Rs. 2130.00 [Rs. Two Thousand One Hundred and Thirty Only (in words)] has been deducted and a sum of Rs. 2130.00 [Rs. Two Thousand One Hundred and Thirty
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 HYDERABAD

Date 02-Jul-2019 (Signature of person responsible for deduction of Tax)

Designation: DIR HR OPS PAYROLL Full Name:CHITTARANJAN KUMAR

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

Page 2 of 2
 FORM NO. 16
PART B
Certificate under Section 203 of the Income-tax Act, 1961 for tax deducted at source on salary

Certificate No. SPHCZMA Last updated on 14-Jun-2019

Name and address of the Employer Name and address of the Employee
OPTUM GLOBAL SOLUTIONS (INDIA) PRIVATE LIMITED
5TH 6TH & 7TH, SUNDEW PROPERTIES SEZ, APIIC
LAYOUT,SURVEY NO.64, TAMTAM EDIGA HARISH KUMAR
HITECH CITY, MADHAPUR, HYDERABAD, TELANGANA - 500081 7 -4-423/A, KALYAN NAGAR BALANGAR, HYDERABAD,
Telangana HYDERABAD -500042 Telangana
+(91)40-69991898
CHITTARANJAN_KUMAR@UHG.COM

PAN of the Deductor TAN of the Deductor PAN of the Employee

AAACQ2188G HYDQ00152F BJAPK1447H

CIT (TDS) Assessment Year Period with the Employer

From To
The Commissioner of Income Tax (TDS)
Room No. 411, Income Tax Towers, 10-2-3 A.C. Guard , 2019-20 01-Apr-2018 31-Mar-2019
Hyderabad - 500004

Details of Salary Paid and any other income and tax deducted Rs. Rs.

1. Gross Salary

(a) Salary as per provisions contained in section 17(1) 456946.00

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 456946.00

(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) 56616.00

Page 1 of 4
Certificate Number: SPHCZMA TAN of Employer: HYDQ00152F PAN of Employee: BJAPK1447H Assessment Year: 2019-20

Amount of any other exemption under section 10

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

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

Total amount of exemption claimed under section 10 [2(a)+2(b)

(h) 56616.00
+2(c)+2(d)+2(e)+2(g)]

3. Total amount of salary received from current employer [1(d)-2(h)] 400330.00

4. Less: Deductions under section 16

(a) Standard deduction under section 16(ia) 40000.00

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

(c) Tax on employment under section 16(iii) 2400.00

5. Total amount of deductions under section 16 [4(a)+4(b)+4(c)] 42400.00

6. Income chargeable under the head "Salaries" [(3+1(e)-5] 357930.00

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 [7(a)+7

8. 0.00
(b)]
9. Gross total income (6+8) 357930.00
10. Deductions under Chapter VI-A

Deduction in respect of life insurance premia, contributions to

(a) 16985.00
provident fund etc. under section 80C

Deduction in respect of contribution to certain pension funds

(b) under section 80CCC 0.00

Deduction in respect of contribution by taxpayer to pension

(c) scheme under section 80CCD (1) 0.00

(d) Total deduction under section 80C, 80CCC and 80CCD(1) 16985.00

Deductions in respect of amount paid/deposited to notified

pension scheme under section 80CCD (1B)
(e) 0.00

Page 2 of 4
 Certificate Number: SPHCZMA TAN of Employer: HYDQ00152F PAN of Employee: BJAPK1447H Assessment Year: 2019-20

Deduction in respect of contribution by Employer to pension

(f) scheme under section 80CCD (2) 0.00

Deduction in respect of health insurance premia under section

(g) 0.00
80D

Deduction in respect of interest on loan taken for higher

(h) education 0.00
under section 80E
Total Deduction in respect of donations to certain funds,
(i) 0.00
charitable institutions, etc. under section 80G
Deduction in respect of interest on deposits in savings account
(j) 0.00
under section 80TTA

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

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

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

(l) 0.00
Chapter VI-A
Aggregate of deductible amount under Chapter VI-A [10(d)+10
11. (e)+10(f)+10(g)+10(h)+10(i) 16985.00
10(j)+10(l)]

12. Total taxable income (9-11) 340945.00

13. Tax on total income 4547.00

14. Rebate under section 87A, if applicable 2500.00

15. Surcharge, wherever applicable 0.00

16. Health and education cess 82.00

17. Tax payable (13+15+16-14) 2129.00

18. Less: Relief under section 89 (attach details) 0.00

19. Net tax payable (17-18) 2129.00

Verification
I, CHITTARANJAN KUMAR, son/daughter of SHIV SHANKAR SINGH .Working in the capacity of DIR HR OPS PAYROLL
(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.

HYDERABAD (Signature of person responsible for deduction of

Place
tax)
Full
Date 02-Jul-2019 CHITTARANJAN KUMAR
Name:

Page 3 of 4
 Certificate Number: SPHCZMA TAN of Employer: HYDQ00152F PAN of Employee: BJAPK1447H Assessment Year: 2019-20

2. (f) Break up for ‘Amount of any other exemption under section 10’ to be filled in the table below
Amount of any other exemption
Sl. under section 1o Gross Amount Qualifying Amount Deductible Amount
No.
Rs. Rs. Rs. Rs.
1.
2..
3.
4.
5.
6.

10(k). Break up for ‘Amount deductible under any other provision(s) of Chapter VIA ‘to be filled in the table below
Amount deductible under any
Sl. other provision(s) of Chapter Gross Amount Qualifying Amount Deductible Amount
No. VIA
Rs. Rs. Rs. Rs.
1.
2.
3.
4.
5.
6.

HYDERABAD (Signature of person responsible for deduction of

Place
tax)
Full
Date 02-Jul-2019 CHITTARANJAN KUMAR
Name:

Page 4 of 4
 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 the Employer: OPTUM GLOBAL SOLUTIONS (INDIA)
PRIVATE LIMITED
5TH 6TH & 7TH, SUNDEW PROPERTIES SEZ,
APIIC LAYOUT,SURVEY NO.64, HITECH CITY,
MADHAPUR, HYDERABAD, TELANGANA-
500081
2) TAN: HYDQ00152F
3) TDS Assessment Range of the Employer : The Commissioner of Income Tax (TDS) Room
No. 411, Income Tax Towers, 10-2-3 A.C. Guard
4) Name of Employee: T E HARISH KUMAR
Designation / Career Level: TECH SUPPORT ANALYST
PAN: BJAPK1447H
5) Is the employee a director or a person with substantial interest in the company No
(where the employer is a company) :
6) Income under the Head "Salaries" of the Employee: 3,57,930.00
(Other than from perquisites)
7) Financial year : 2018-19
8) Valuation of Perquisites
Sr. Value of perquisite as per rules Amount, if any paid by Amount of Taxable
Nature of perquisite
No (Rs.) employee (Rs.) perquisite (Rs.)

1 Accommodation 0.00 0.00 0.00

2 Cars/Other automotive 0.00 0.00 0.00
3 Sweeper, gardener, watchman or personal attendant 0.00 0.00 0.00
4 Gas, electricity, water 0.00 0.00 0.00
5 Interest free or concessional loans 0.00 0.00 0.00
6 Holiday expenses 0.00 0.00 0.00
7 Free or concessional travel 0.00 0.00 0.00
8 Free meals 0.00 0.00 0.00
9 Free Education 0.00 0.00 0.00
10 Gifts, vouchers, etc 0.00 0.00 0.00
11 Credit card 0.00 0.00 0.00
12 Club expenses 0.00 0.00 0.00
13 Use of movable assets by employee 0.00 0.00 0.00
14 Transfer of assets to employee 0.00 0.00 0.00
15 Value of any other benefit/amenity/service/privilege 0.00 0.00 0.00
16 Stock options 0.00 0.00 0.00
17 Other benefits or amenities 0.00 0.00 0.00
18 Total Value of Perquisites 0.00 0.00 0.00
19 Value of profits in lieu of salary as per Section 17 (3) 0.00 0.00 0.00
9) Details of tax
(a) Tax Deducted from Salary of Employee u/s 192(1) 2,130.00
(b) Tax paid by Employer on behalf of the Employee u/s 192(1A) 0.00
(c) Total tax paid 2,130.00
(d) Date of payment into Government treasury Refer Form 16

DECLARATION BY EMPLOYER
I, CHITTARANJAN KUMAR, son of SHIV SHANKAR SINGH working in the capacity of DIR HR OPS PAYROLL, do
hereby declare on behalf of OPTUM GLOBAL SOLUTIONS (INDIA) 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.
For OPTUM GLOBAL SOLUTIONS (INDIA) PRIVATE
LIMITED

Signature of the person responsible for deduction of tax

(Digitally Signed Document)

Place : HYDERABAD Full Name : CHITTARANJAN KUMAR

Date : 05-Jul-2019 Designation : DIR HR OPS PAYROLL
T E HARISH KUMAR/001210971/1
 ANNEXURE TO FORM NO. 16
Breakup for 10(a) and 10(k) - Chapter VI A deduction details
1) Name and Address of the Employer: OPTUM GLOBAL SOLUTIONS (INDIA) PRIVATE
LIMITED
5TH 6TH & 7TH, SUNDEW PROPERTIES SEZ,
APIIC LAYOUT,SURVEY NO.64, HITECH CITY,
MADHAPUR, HYDERABAD, TELANGANA-500081
2) Name of Employee: T E HARISH KUMAR
Designation / Career Level: TECH SUPPORT ANALYST
PAN: BJAPK1447H

1. Breakup for 10(a) - Section 80C Gross Amount Deductible Amount

Employee Provident Fund 16,985.00 16,985.00

Total 16,985.00

For OPTUM GLOBAL SOLUTIONS (INDIA)

PRIVATE LIMITED

Signature of the person responsible for deduction of tax

(Digitally Signed Document)
Place : HYDERABAD Full Name  : CHITTARANJAN KUMAR
Date : 05-Jul-2019 Designation : DIR HR OPS PAYROLL
T E HARISH KUMAR/001210971/2