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•I1 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 •~ RESIDEN1lAI./OFFICE NO.WITHSTU CODE1M§> MOBILE NO. PHONE • I 1 1 1 1 I 1 1 1 1 1 1 1 II 1 1 1 1 1 1 1 1 1 IIMl> • 0 0 0 • 0 0 0

~ Fill only one ~ Tax Refundable ~ Tax Payable ~ Nil Tax Balance ~ ~ Fill only one: tiled ~ Before due date-139(1) ~ After due date-139(4) ~

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0 Government ~ 0 PSU ~ 0 Others 0 Resident ~ 0 Non Resident ~ 0 Resident but not ordinarily resident 0
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Revised Return-139(5) OR in response to notice ~

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148 ~ 0 153A/153C

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If revised

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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

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Income from other sources

Ensure to fill "Sch TDS2" given in Page 2

Gross Total Income (81 + 82 + 83)

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~ C4 (80eeF)

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~ C10 (8000) ~ C13 eM[)

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SEAL, DATE AND SIGNATURE OF RECEIVING OFFICIAL

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TOTAL TAX AND CESS ( 01+ 02 )

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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 Income-tax Act, 1961, in respect of income chargeable to Income-taxforthe previous year relevant to the Assessment Year 2011-12. • Place

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