2011-12ITR-1, PA~

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MIDDLE NAME

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1M> INCOME
TAX WARD/CIRCLE

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ROAD/STREET

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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) ~

• IruJ> EMAIL

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ADDRESS


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Fill only one ~

0 Government ~ 0 PSU ~ 0 Others 0 Resident ~ 0 Non Resident ~ 0 Resident but not ordinarily resident 0
142(1) ~

Revised Return-139(5) OR in response to notice ~

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148 ~ 0 153A/153C

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Receipt Number 01 Original Return

Date of Filing Original Return

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

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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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C3 (80eed C6 (8000)

~ C4 (80eeF)

~ C7 ~ooOd
~ C10 (8000) ~ C13 eM[)

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Total Deductions (Add Items C1 to C13 ) Taxable Totallncome( 84 - C14 )
FOR OFFICIAL USE ONLY

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SEAL, DATE AND SIGNATURE OF RECEIVING OFFICIAL

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.I • [g) ~I ~ ~I 111 II1 IIIIIIIII ~ (1) Enlerlhe tetal 01 column(iv) 01 Sch TDS1 and Sch TOS2 in 011 (2) Conlinue in Supplemenlary Schedule TDS2 ilyou cannollill wilhin Sch TO~ 1 ':=1=====:::::1 1 ~I ~=====~ 1 ~I • • • ~ :=======::::::: ~ ::=::=:=:...:::::: ~ ~UIW • ~ . Total Interest u/s 234A/234B/234C Total Self Assessment Tax Paid . 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.. Agricultural Income < ~ 5000/-)~ LWI!JJ • • • • • • • • • • • • • Tax Payable On Totallncome(C15) ~ D1LWI!JJ Relief u/s 89 ~ 04 LWI!JJ ~ 07 LWI!JJ ~D10LWI!JJ ' ...DETAILS OF ADVANCE TAX AND SELF ASSESSMENT TAX PAYMENTS • • n • ~ ~DIW • • lID> ~ ~*::=::::::::=:::=:: • ~ ~DIW • • IW~ • ~~~~=*~~ ~ ~UIW • ~~ • ~ ~UIW • • ~~ :=::===***:.::*=*~~:::::..... • aSR CODE(col TAX PAID(coLiv) • 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 ~I 1~1 1 1 1 1 1 1 1 1SIGN HERE + I I: • TRP Signature · ==::=:::== · ..DETAILS OF TAX DEDUCTED AT SOURCE FROM SALARY [AsperForm16issuedbyEmployersl • • • III 1 ~ .::=::=:=~ ~::=::=:=:..-'--'--'--'1 1 -'-1. • Place • • ==============~~I~I~I~I~I~I~I~I~I~I~I~==~I~I~I~~I~I~I ~I~I~I~I================: • . in respect of income chargeable to Income-taxforthe previous year relevant to the Assessment Year 2011-12.• ~D15 ACCOUNT No...:::. • • . Secondary & Higher Education Cess Total Tax and Interest (06+07) Total TOS Deducted If 012 >08) 1 1 1~ 03 LWI!lll 1 I : • 1 1 1 ~ 06 LWI!JJ 1 1 1•• 1 1 1 ~ 09 LWI!JJ 1 1 1: • 1 1 1 ~D12 LWI!JJ 1 1 1•• • 111 • • 016 I I I I I I I I I I· Balance Tax After Relief ( 03-04-05) Total Advance Tax Paid Total Prepaid Taxes (09+010+011) TOTAL TAX AND CESS ( 01+ 02 ) I I I: • • • • : • VERIFICATION I.::.. 1961......::=::=:=~ • 1:======::::::: ~UIW 1 1 1~UIW 1. ~D13LWI!JJ .::. ~ son/daughter of ~ solemnly declare thatto the best of my knowledge • and belief... 1...... Tax Payable ( 08-012. . '- I ~ ..!-I I .ii) In Supplemenlary Schedule IT il you cannollill wilhin Sch IT 1~ III III 1~ 1~ 1 (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 NAME OF THE DEDUCTOR(col..:::...ii! • • -DETAILS DEDUCTED OF TAX AT SOURCE INCOME THAN FROM OTHER SAl.. If 08>012) 1 1 ~ 02 LWI!JJ 05 1 1 I~ LWI!JJ 08 1 1 I~ LWI!JJ ...~~ ~ • • TAN(coLi) ~~ 1 • : • ~~ ~ ~ 1 1 ~ TAN(coLi) 1) Enler Ihe lola Is 01 Advance Tax and Sell Assessmenl Tax In 09 and 10 (2) Conllnue NAME OF THE EMPLOYER(col.. 1 1 1~011 LWI!JJ ...ARY[As16A issued by Deduclor(s)] per Form • ID> ~ ._I... 1 1 1~014 I Relief u/s 90/91 Refund ( 012-08. ~ MICRCODE • ~017Type of account: ~ 0 Current ~ 0 Savings ~ 018Fill only one: Refund by ~ 0 chequeor ~ 0 depositeddirectly into your bankaccount : ~D19 Exempt income only for reporting purposes (From Dividends....

. ""1""""1 r-r....I .1111111111111111111111111111111111111111111111111111111111111111111111111111111111111 FIRST NAME • 1 MIDDLE NAME rRilENTJiour rr I I 1 ............................. ~LllJLIJ___ ~LllJLIJ LllJLIJ ~LllJLIJ ~LllJLIJ__ ~LllJLIJ __ ~LllJLIJ ""I""""I~LllJLIJ ~LllJLIJ__ ~LllJLIJ r-r.. .......:..... ~ ~DIW r-r.............._I ................................... . --......--... ""1""""1 r-r....... 1 1--............. ""1""""1 r-r.... ~ ::::::::::::::::::::::: • __ ~DIW ......-1 .......1 I__...... ""1""""1 r-r.... ""1""""1 r-r.................1 1 1--..... __ ~DIW : ~LllJLIJ ~LllJLIJ__ ~DIW : ~DIW • ~LllJLIJ • ~LllJLIJ__ ~DIW • ~DIW ~DIW : r-r... II111 II111 II111 IIIII IIIII LllJLIJ ~LllJLIJ ~LllJLIJ__ ~LllJLIJ LllJLIJ ~LllJLIJ ~LllJLIJ__ ~LllJLIJ ~ • : : • • • : • • • r-r...... ""1""""1 r-r..... ""1""""1 r-r.................... r-r.................................... r-r.... ~ ~~ ~~ ~~ ~~ ~~ IIIIIIIII IIIIIIIII 111II111I I ~.......... ""1""""1 r-r....... . ~ ~LllJLIJ__ ~LllJLIJ LllJLIJ ~LllJLIJ ~LllJLIJ__ ~LllJLIJ LllJLIJ ~LllJLIJ r-r................. ""1""""1 r-r. ""1""""1 r-r................ 1 · · • · • · • • · • · • · • • · • · • · · • · • · • · · • · • · • • · • · • · • SU PPLEM ENTARY • •~ • ~ 111111111 •~ ~ 111II111 • 111II111 TAN(coLi) (To be used only after exhausting items S1-S3 of Schedule TOS1 in main form etc) NAME OF THE EMPLOYER(col................1... r-r.:...ii) ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 111 II111 ~ ~ ~ ~ 111111111 111111111 111111111 111111111 111111111 111II111I 111II111I 111II111I 111111111 111111111 111111111 111111111 111111111 111111111 111111111 111 111 111 III III ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ LllJLIJ ~LllJLIJ ~LllJLIJ__ ~LllJLIJ LllJLIJ ~LllJLIJ ~LllJLIJ__ ~LllJLIJ r-r. ""1""""1 r-r....... ""1""""1 r-r...............................r-""I"""" • r-r....... • • ~~~~-.. ~ : • • • : • • : • • : __ ~DIW ~DIW r-r. ~DIW : r-r.... 1---'--1 1 1 ....... ~ __ ~DIW ~DIW r-r.. r-r... ! AY2011-12l • LAST NAME 11111111111111111 11 1111111111 .....

LW ~LLLUJ ~Ll. ".LW ~Ll.LW ~Ll.LW ~Ll.LW • ~UIW ~Ll.LW ~Ll.LW ~Ll.LW ~Ll.LW ~Ll. .iii) ~ ~DIW ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ • 1m ~ • IW ~ • • Ifi) ~ • • IIW~ • • IIW~ IIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIIII IIIIIIII IIIIIIII IIIIIIII IIIIIIII IIIIIII IIIIIIII ~DIW ~DIW ~DIW ~Ll.II§)~ 111II111 • IIIIIIII TAN(coLi) IIIII II MIDDLE NAME rRilENTliour rr I I I II LAST NAME AY2011-12l I• of Schedule TDS2 in main form elc • IIIIIIIIII IIIIIIIIIIIIII (To be used only after exhausting ilemsTH4 NAME OF THE DEDUCTOR (coLii) ~Ll.LW TAX DEDUCTED(col.LW ~Ll.LW ~DIW ~DIW ~DIW • IIID~ • • IIW~ • • IIH>~ • IIW~ • • m~ • • 1TI1>~ ~LLLUJ ~Ll.LW ~UIW ~Ll.LW ~Ll.ril III 11111 11111111111111111111111111II 111111111111111111111111111111111111111111 1 I 1 FIRST NAME •IIIIIIIIIIIII • SUPPLEMENTARY • •~ ~ IIIIIIIII • .LW ~Ll.LW ~Ll.LW • IIW~ • IIW~ • • m~ • • m~ • • W~ • W~ ~DIW ~UIW • • W~ • ~~ • ~~ • m~ • · · I ~LLLUJ ~LLLUJ ~LLLUJ ~LLLUJ ~LLLUJ ~DIW ~UIW ~LLLUJ ~LLLUJ ~LLLUJ ~LLLUJ ~LLLUJ • m~ I • • m~ I ~~ ~UIW ~UIW IIIIIIIII IIIIIIIII ~LLLUJ ~LLLUJ ~UIW ~UIW ~LLLUJ ~LLLUJ • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • [W.LW ~Ll.LW ~Ll.

...........&....... .... ........................ FIRST NAME IIIIII II MIDDLE NAME rRilENTliour ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ rr I I I II LAST NAME AY 2011-121 I• IIIIIIIIII IIIIIIIIIIIIII (To be used only aHer exhausting items R1-R5 of Schedule IT in main form etc) CHALLAN NO(coLiii) ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .........&......&...&....... ... • ......... .........&.... ............................ ............ ...&................ ...~ _ ~ : ~~I...ril III 1111111111 1111111111111111111111 III 1111111III 11111111111111111111111111111111 1 •IIIIIIIIIIII • SUPPLEMENTARY • ~ ~I • BSR CODE(col ") • ... ............ . .. .............. . ...... UJ. .... LLLW ~ LLLW ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ • ~~I _ ---------.. ~ ~ ~ ~ : fW~I : ~~I • ~~I • ... .......... ... ~... ~.....&...................... DIW DIW DIW DIW DIW DIW DIW DIW DIW DIW DIW • ~ ~11"""""I~--r"""'T"""-r-T"""""I ~ ~ ~ I HID~I ~·I LLLW ..... • ~ ~11"""""I~__r"""'T"""_r_T"""""I • • ~ ~I : ~ ~I • ~~I • IDj)~I-----------: ~~I : 8W~I • ~~I ...... .........jjj ~ UJ...&.....&.&.................. .....&........&....... LLLW ~ LLLW ~ LLLW ~ LLLW ~ LLLW ~ LLLW ~ DIW DIW DIW DIW TAX PAID( coLiv) • 1ill>~1 • ·~~I-----------• .. ~ • ~~I • Iru> ~11"""""I~--r"""'T"""-r-T"""""I • ............................. ...................... • ....&...&............... .....................&....................&... • ffi§>~I-----------: H1§)~I........&............ ..jjj ~ UJ.......&... .............&...jjj • ~~I _ ---------_ : ~~I _ ---------_ · -----------• • w~1 • IW~ 11"""""I~--r"""'T"""-r-T"""""I ....&.... ...............

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