) M0000 0 00 meee Are AY 20 © (AD FIRST NAME (A MIDDLE NAME Pheer og ABLAST NAME (Md PERMANENT ACCOUNT NUMBER Poder | wm AS SEX (AB DATE OF BIRTH [id INCOME TAX WARD/CIRCLE © 0 male © remae [D[D[MIMDY Ly YIV] © (A® FLAT/DOOR/BUILDING [AD ROAD/STREET wee ta AID AREALOCALITY (At) TOWN/CITY/DISTRICT mLLLLLi it m Aid) STATE {a1 country [AY PINCODE mc (A1S EMAIL ADDRESS i iS MOBILE NO.1/RESIDENTIAL/OFFICE PHONE NO.WITH STD CODE —_[A17) MOBILE NO.2 : cere di i} rity neyo rsong to O Goverment » © PSU> O ots (99 Fi oy one > © Tax Raundabl» © Tax Payables © Wi Tax Balance 0) Flan one» © Reset» © Non Rasen» © Resin ut ct rina resent 2D Ft ny oe es» © Ono Bt ea-351)» © ate ue cat-1384 O ise Retun-129(5) OR in rsponse to noice» 1398) > nous . ‘Whether Person governed by Portuguese Civil Code under section 5A») 23) \"A22 is applicable, rr ad fovea Pou > BaD pict Spouse © pzp irovaew doiecive >| TT | | | | | LOLLY] > [ ezept umber of Orga elu Dae of Fling of Original Reurn [H2B ted in responce to note ue 120(9)142(1y148/15QA/I59C > Ton Income from Salary/Pension > BI HOLES} Ensure to fil “Sch TOS1" given in Page 2 Income from One House Property » © Self Occupied » © Let out > B2 ( Income fram other sures men stmee> -e [ITIP (TELE Ensure to fil “Sch TOS2" given in Page 2 Gross Total Income (B1 + B2 + B3) » Bd ( ETDS RW Oe [TTT TT] > cz caccs » 63 > esq = [TT TT) cm) = TT IT) sor coo) [PLT] cee §— CCLE D> os ce DOECEEEI »€10 (OEE) rere) [TT [TI] YT |>cr2 Goce) TL -erseoaaa| | | [|] | | | -crasoaaol_] > 15 GORRB >cresonas «= fT | | > C1707) Coo LI TIT) [aE] Total Deductions (Add items C1 toC18) > C19 OUI (2) Taxable Total Income (B4 - C19) rem ( PITITITITITH) = FOR OFFICIAL USE ONLY >|STAMP RECEIPT NO. HERE ‘showing os, mark the epatve signin rack ait‘Tax Payable On Total Income (¢2q Rebate u/s 870 1 Litt it oz L Surcharge, if C20 exceeds 1 crore ess On (D3+D4) 4 Litiiiil “05 LLii iii) Reliet u/s 89 Balance Tax After Relief (06-07) 7 Litiiit 08 Litt it Total Interest w/s 2348 Total Interest ws 2346 p10 >on Total Advance Tax Paid 13 I Total Taxes Paid (013+D14+D15) >D16 Total Self Assessment Tax Paid p14 LIiITI Total Payable (D12- D1, If D12>D16) DIT PT > D19 account. (tin an a be dd BT D2! esc cove er of ‘sp00r0ance withthe provisions ofthe Income-tax Act 1961, in respect ot income chargeable to Income tax forte pre SIGN HERE > U1the return has been prepared by & Tax Return Preparer (TRP) giv further details as below Name ofthe TAP TAP PIN [10 Digit] te be paid to TRP BSR CODE(co!.) ‘DATE OF DEPOSIT( coli) Beags COGDESE (1) eter tots ot advance Tax and Sel Assessment Tax in D13 and D14 (2) Continue in Suppl TAN(col.i) AME OF THE EMPLOYER(col.ii) Si . 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DATE OF DEPOSIT( coli) (CHALLAN NO(co. i) TAK pry =®(TTIITIT]- DIM) -COTTT) » O11 > -COLDLLH BEB z - HEN PE AY 201815