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[summon un me mone. | AY 20 (ad FIRST NAME (A MIDDLE NAME (RB LAST NAME [Rd PERMANENT ACCOUNT NUMBER In sex (RB DATE OF BIRTH (RD) INCOME TAX WARD CIRCLE Male © Female (BB FLAT/DOOR/BUILOING ‘RB ROADISTREET (Ri AREATLOCALITY ‘AIDTOWCITY/DISTRICT Ini STATE ‘RT PINCODE (Rid EMAIL ADDRESS (R15) RESDENTALOE PONENO WT STD ODE (AT MOBILE NO. {R17 Fill only one it you belong to © Government » © PSU » © Others [RTE Fi ony one» © Tax etude» © Tax Payable» © Nl Tax alee (R20 Fi ory one: fied» © Before due date-190(1) » © Ater due dte-139/8) » © Revised Retur-t39(5) OR inrespense entice» 142[1) » 0 148 » © 159W/1530 ) Filmi ane» © Resifent» © Non Reset » Reset ut at oral es (2) it revised ” and cept Huber of Original Return Date of Filing Original Return SS DINE TG rine Income from Salary/Pension > BI Ensure to fill"Sch TDS1” given in Page 2 sowing nse mate apts sgn oat ek Income from One House Property ez() Titi Income from other sources BC) EGHLEE Ensure to fll "Sen TOS2” given in Page 2 Gross Total Income (B1 + B2 + B3) »B4() | > C2 @ucce > C3 goccD > C4 @OCce ] > C5 (80D) ] > C6 (00D) ant . . > C7 goods, | > CB(80E) | > co (ag) | |) i) spec can | ~orrenaaa [| | [|| cre eaaao| | | | | | . : rem m (GE) Taxable Total Income( B4 - C14 ) row (VL TTT IT TT FOR OFFICIAL USE ONLY > [ LL L > D4 Total Inte 07 Total Sel *D10 *D13 Tax Payable ( D8- YET a VESTS in Total Income(C15) Secondary & Higher Education Cess Relief u/s 90/91 COOCOCE »¢ EEO 0 ferest u/s 234A/234B/234C _Total Tax and Interest (D6+D7) Milt i oe |) tii ti) os If Assessment Tax Paid Total TDS Deducted -D12, IfD8>012) Refund ( D12—D8, If D12 >08 ) Mette CLL IAA eee Balance Tax Total Advance Tax Total Pre 2011-12 ITR-1, PAGE 2 TOTAL TAX AND CESS ( D1+ D2) Reliet u/s 89 ‘After Relief ( D3-D4-D5) Pail Taxes ( D9+D10+D11) Bank Account Details ( Mandatory in all cases irrespective of refund due or not) »D15 accounr Wo LIT TTTIT Tit iitt > D16 men cove »D17 type of account »D19 Exempt income » © Current » © Savings »D18 Fill only one: Retund by » © only for reporting purposes (From Dividends, Agricultural Income < & S000/-)» cheque or» © deposited i rectly into your bank account TAN information given inthe rlur correct ad complet an accordance wth the provisions ofthe ncame-tax At, 961, nrespectat incor son daughter of» atthe amount of total income and eter par argable to Income-ax othe previous year elevatiothe Assessment Yea 2011-12, ni decarathat tthe best of my knowledge rs shown therein ate rly stated and are in 1 . 1 Place » > MMT SIGN HERE > . the rt as ben prepared bya Tax Retr Proprar (TAP) gv furor dts blow . 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