First Name

[For Individuals having Income from Salary/ Pension/ family pension & Interest] (Please see Rule 12 of the Income Tax-Rules,1962) (Also see attached Instructions)

Last Name Name of Premises / Building / Village Area / Locality

Assessment Year


Middle Name


Flat / Door / Block No Road / Street / Post Office

Status I - Individual Date of birth (DD/MM/YYYY)



Pin Code

Sex (Select) M-Male

Email Address Designation of Assessing Officer (Ward / Circle)

(Std code) Phone No


Employer Category (if in employment) OTH Return filed under section [Pl see instruction 9(ii)] 11 - u/s 139(1) Revised Date 1

Whether original or revised return?



If revised, enter Receipt no / Date Residential Status RES - Resident 1 Income chargeable under the Head ‘Salaries’(Salary/ Pension) 2 Income chargeable under the Head ‘Other Sources’ a Family Pension 2a b Interest 2b c Total (2a + 2b) 3 Gross Total Income (1+2c) 4 Deductions under Chapter VI A (Section) a 80 C 4a b 80 CCC 4b c 80 CCD 4c d 80 D 4d e 80 DD 4e f 80 DDB 4f g 80 E 4g h 80 G 4h i 80 GG 4i j 80 GGA 4j k 80 GGC 4k l 80 U 4l m Deductions : Suggested Value = 189000 5 Total Income (3 - 4m) 6 Net Agricultural Income (Enter only if greater than Rs. 5,000) 7 Aggregate Income (5 + 6) 8 a Tax payable on Aggregate Income b Rebate in respect of Net Agricultural Income 9 a Tax payable on Total Income (8a-8b) 9a b Surcharge on 9a 9b Education Cess, including secondary and c higher secondary cess on (9a+9b) 9c

2c 3

0 0


4m 5 6 7 8a 8b 0

0 0

d Total Tax, Surcharge and Education Cess (Payable) (9a+9b+9c) 10 Relief under Section 89 10 11 Relief under Section 90/91 11 12 Balance Tax Payable (9d - 10 - 11) 13 a Interest payable u/s 234 A b Interest payable u/s 234 B c Interest payable u/s 234 C d Int payable(13a+13b+ 13c) 14 Total Tax and Int. Payable(12+13d) For Office Use Only Receipt No/ Date



12 13a 13b 13c 13d 14 Seal and Signature of Receiving Official


0 0

15 Taxes Paid 0 a Advance Tax (from item 23) 15a b TDS (column 7 of item 21 +column 7 15b 0 of item 22) 0 c Self Assessment Tax (item 23) 15c 0 d Total Taxes Paid (15a+15b+15c) 15d 0 16 Tax Payable (14-15d) (if 14 is greater than 15d,) 16 0 17 Refund (15d-14) if 15d is greater than 14 17 18 Enter your Bank Account number (Mandatory in case of refunds) 19 Select Yes if you want your refund by direct deposit into your bank account, No Select No if you want refund by Cheque 20 In case of direct deposit to your bank account give additional details MICR Code Type of Account(As applicable)

24 Other Information (transactions reported through Annual Information Return) (Please see instruction number-9(ii) for code) Sl Code Amount (Rs) Sl Code Amount (Rs) a 001 b 002 c 003 d 004 e 005 f 006 g 007 h 008 25 Tax-exempt interest income (for reporting purposes only) VERIFICATION I, (full name in block letters), son/daughter of solemnly declare that to the best of my knowledge and belief, the information given in the return thereto 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 of the Income-tax Act, 1961, in respect of income chargeable to Income-tax for the previous year relevant to the Assessment Year 2008-09 Place Date Sign here ->

26 If the return has been prepared by a Tax Return Preparer (TRP) give further details as below: Identification No of TRP Name of TRP Counter Signature of TRP



If TRP is entitled for any reimbursement from the Government, amount thereof (to be filled by TRP)

21 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)] Income Tax Tax Deduction charg Deduction payable Account Name of eable under (incl. SI.No Number the Address City State PinCode under the Chapter surch. (TAN) of the Employer head VI-A and Employer Salaries edn.cess) (1) (2) (3) (4) (5) (6) 1 2

Total tax Deducted (7)

Tax payable/ refundable (8)

(Click + to add more rows to 22) TDS on Interest above. Do not delete blank rows. Blank rows will not be included In the ITR) 22 Details of Tax Deducted at Source on Interest [As per Form 16 A issued by Deductor(s)] Tax Deduction Account Name of SI.No Number the (TAN) of the Deductor Deductor (1) 1 2 (2) (3) Amount PinCode paid/ credited (4) Date of Payment / Credit (5) Amount out of Total tax (6) claimed Deducted for this year (6) (7)




(Click + to add more rows to 22) TDS on Interest above. Do not delete blank rows. Blank rows will not be included In the ITR)

23 Details of Advance Tax and Self Assessment Tax Payments Bank Detals & Branch Date of Serial Deposit Amount Sl No Name of the BSR Code Number of (DD/MM/ (Rs) Branch Challan Bank YYYY) 1 2 3 4 5 (Click '+' to add more rows to 23) Tax Payments. Do not delete blank rows. Blank rows will not be included In the ITR)