NAME :

CPF:
ANNUAL INCOME TAX RETURN

INCOME TAX - INDIVIDUAL

FISCAL YEAR:
CALENDAR YEAR:

SUMMARY -----------------------------------------------------------------(Amounts in US$)

TAXABLE INCOME
Received from juridical persons by the holder
Received from juridical persons by the holders dependents
Received from individuals to the holder
Received from individuals to the holders dependents
Received from abroad
Taxable final income from rural activities
TOTAL

0
0
0
0
0

DEDUCTIONS
Contributions to the official retirement fund
Contributions to private retirement funds and FAPI
Dependents
Educations tuitions fees
Medical expenses
Alimony
Cash register book
Total
TAX DUE
Calculation basis
Tax
Incentive deductions
Tax due I
Contribution to official pensions fund for domestic
employees
Tax due II
TAX PAID
Holders income tax withheld at source
Holders dependents income tax withheld at source
Monthly mandatory tax payment
Tax on extra personal income tax
Tax paid abroad
Income tax withheld (Operation at the Stock
Exchange Law n 11033 of 2004)
TOTAL

0
0
TAX TO BE REFUNDED
BALANCE OF TAX TO BE PAID
0
0

0
0
0
0
0

PAYMENTS IN INSTALMENTS
Instalment amount
Number of instalments
BANK INFORMATION
Bank
Agency
Debit account
TAX TO BE PAID
Capital gains Currency in kind

EQUITY EVOLUTION
Assets and rights on Dec 31, 200?
Assets and rights on Dec 31, 200?
Actual debts and encumbrances on Dec 31, 200?
Actual debts and encumbrances on Dec 31, 200?
Spouses information
OTHER INFORMATION
Exempt and no-taxable income
Income subject exclusively to taxation at the source/income subject to conclusive taxation
Tax paid on Capital Gains
Tax paid in Foreign Currency Assets, rights, finance investments
Total of income tax withheld (Operation at the Stock Exchange Law n 11033 of 2004), according to
information supplied by the holder
Tax paid on variable income
Donations to Political Parties, Financial Committees and Candidates

Brazilian individual tax payer registry

Currency rate used: 0,5676 US$/R$
Planed or programmed individual retirement fund

0
0

0
0
0

0
0