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2011-12ITR-1, PA~

AY20

• I@ FIRST NAME

: I 1 1 1 1 1 1

I@LASTNAME

: I 1 1 1 1 1 1

~ MIDDLE NAME •

I I •

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 .

1M> PERMANENT ACCOUNT NUMBER •

111111111111111111111111111111111111:

1M> INCOME TAX WARD/CIRCLE

~ ROAD/STREET

I 1 1 1 1 1 1 1 1 1

1M]) TOWN/CITY/DISTRICT

...... ~~~~~~~~~~~~~~~~1~~~~~~~~~~~~~~~1 ••

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 .

~PINCODE •

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 •

•

~~~~~~~~ ~----------------------------------~.

•

1 1 1 1 1 1 1 1 1 1 1 1 I:

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

• IruJ> EMAIL ADDRESS •

• I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I·

• ~ RESIDEN1lAI./OFFICE PHONE NO. WITH STU CODE 1M§> MOBILE NO. •

• I 1 1 1 1 I 1 1 1 1 1 1 1 II 1 1 1 1 1 1 1 1 1 IIMl> Fill only one il you belong to ~ 0 Government ~ 0 PSU ~ 0 Others •

• •

~ Fill only one ~ 0 Tax Refundable ~ 0 Tax Payable ~ 0 Nil Tax Balance ~ Fill only one ~ 0 Resident ~ 0 Non Resident ~ 0 Resident but not ordinarily resident

• •

~ Fill only one: tiled ~ 0 Before due date-139(1) ~ 0 After due date-139(4) ~ 0 Revised Return-139(5) OR in response to notice ~ 0 142(1) ~ 0 148 ~ 0 153A/153C

: ~ If revised ~ 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 and ~ 1 1 1 1 1 1 1 1 1 :

• Receipt Number 01 Original Return Date of Filing Original Return •

• • • • • • • • • • • • • • • • • • • •

Income from Salary/Pension

~ Ensure to fill "Sch TDS1" given in Page 2

Income from One House Property

Income from other sources

~ Ensure to fill "Sch TDS2" given in Page 2

Gross Total Income (81 + 82 + 83)

~ C5 c::mJ _I _I do.!.-..._

~ CO (]ID DlllJ ~C118000~ LLLW

, , ~

•
C3 (80eed LUJ •
~
•
~ C6 (8000) o 1 ! •
c9~DIW •
~ •
~ C12 ~moocUI! 1 ! •

•
•
~ C14 U 1 ! 1 ! 1 ! 1 ! 1 1 1 •
•
~ C15 ()DIWI!I I 1 1 1 • ~ C4 (80eeF)

~ C7 ~ooOd LW_ ...

~ C10 (8000) .... 1 .&..1 .:ho! .....

~ C13 eM[) LW:...& ..........

Total Deductions (Add Items C1 to C13 ) Taxable Totallncome( 84 - C14 )

FOR OFFICIAL USE ONLY

+ STAMP RECEIPT NO. HERE

SEAL, DATE AND SIGNATURE OF RECEIVING OFFICIAL

L

• Tax Payable On Totallncome(C15) Secondary & Higher Education Cess TOTAL TAX AND CESS ( 01+ 02 ) I :
• ~ D1LWI!JJ I 1 1 ~ 02 LWI!JJ 1 1 1 ~ 03 LWI!lll 1
• Relief u/s 89 Relief u/s 90/91 Balance Tax After Relief ( 03-04-05) •
• ~ 04 LWI!JJ 1 1 I~ 05 LWI!JJ 1 1 1 ~ 06 LWI!JJ 1 1 1 •
• Total Interest u/s 234A/234B/234C Total Tax and Interest (06+07) Total Advance Tax Paid •
• ~ 07 LWI!JJ 1 1 I~ 08 LWI!JJ 1 1 1 LWI!JJ 1 1 1 :
• ~ 09
• Total Self Assessment Tax Paid Total TOS Deducted Total Prepaid Taxes (09+010+011) •
• ~D10 LWI!JJ 1 1 1 ~ 011 LWI!JJ 1 1 1 ~D12 LWI!JJ 1 1 1 •
• ' , , , •
Tax Payable ( 08-012, If 08>012) Refund ( 012-08, If 012 >08)
• ~D13 LWI!JJ 1 1 1 ~ 014 1 1 1 •
• •
, , , , • •

• ~D15 ACCOUNT No. ~ 016 MICRCODE I I I I I I I I I I·

• ~ 017 Type of account: ~ 0 Current ~ 0 Savings ~ 018 Fill only one: Refund by ~ 0 cheque or ~ 0 deposited directly into your bank account • : ~D19 Exempt income only for reporting purposes (From Dividends, Agricultural Income < ~ 5000/-)~ LWI!JJ I I I:

VERIFICATION

•

•

• I, ~ son/daughter of ~ solemnly declare thatto the best of my knowledge •

and belief, the information given in the return is correct and complete and that the amount of total income and other particulars shown therein are truly stated and are in

• accordance with the provisions ofthe I ncome-tax Act, 1961, in respect of income chargeable to Income-taxforthe previous year relevant to the Assessment Year 2011-12. •

: Place ~I 1 ~ 1 1 1 1 1 1 1 1 1 SIGN HERE + I I :

• If the return has been prepared by a Tax Return Preparer (TRP) give further details as below •

Name of the TRP TRP PIN [ 10 Digit I Amount to be paid to TRP TRP Signature

==============~~I~I~I~I~I~I~I~I~I~I~I~==~I~I~I~~I~I~I ~I~I~I~I================:

•

•

- DETAILS OF ADVANCE TAX AND SELF ASSESSMENT TAX PAYMENTS

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aSR CODE(col n

TAX PAID( coLiv)
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- DETAILS OF TAX DEDUCTED AT SOURCE FROM SALARY [AsperForm16issuedbyEmployersl

•

• TAN(coLi) NAME OF THE EMPLOYER(col.ii)

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• ~ (1) Enlerthe total of column(iv) of Sch TDS1 and Sch TDS2 in D11 (2) Continue in Supplementary Schedule TOS1 if you cannot liII within Sch TDS1

•

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• • • •

- DETAILS OF TAX DEDUCTED AT SOURCE FROM INCOME OTHER THAN SAl.ARY[As per Form 16A issued by Deduclor(s)]

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MIDDLE NAME LAST NAME

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AY2011-12l

FIRST NAME

• 1 1 1 1 1 1 1 1 1 1 1 1 1

SU PPLEM ENTARY (To be used only after exhausting items S1-S3 of Schedule TOS1 in main form etc)

•

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NAME OF THE EMPLOYER(col.ii)

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FIRST NAME

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AY2011-12l

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SUPPLEMENTARY (To be used only after exhausting ilemsTH4 of Schedule TDS2 in main form elc

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FIRST NAME MIDDLE NAME LAST NAME

• I I I I I I I I I I I I I I I I I I II I I I I I I I I I I I I I I I I I I I I I I I I I I I •

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