Government of Pakistan

Department of Income Tax

Office of the ____________

The Commissioner
__________ _______________________________________
_________________________________________________ (City)

Dear Sir,

I,

____________________________________________________________________

of

_______________________________________________________________________ hereby declare

a.

That my total income computed in accordance with the provisions of Income Tax Ordinance,
2001 (XLIV of 2001), during the year ending on ______________ being the income year for
the assessment for the year ending on the ________________ amounted to Rs.
_______________.

b.

That the total tax chargeable in respect of such total income is Rs. ______________.

c.

That the total amount of tax paid is Rs. ______________.

I, therefore, request that a refund of Rs. ________________ may be allowed to me.

Yours faithfully ______________________

Signature __________________________
NTN ______________________________
Address ___________________________

I hereby declare that I am resident/ non-resident* and that what is in this application is correct.

Date ___________________

* Delete whichever is in applicable.

Signature _________________