SAHAJ

FORM

INDIAN INCOME TAX RETURN

[For Individuals having Income from Salary / Pension / Income from One House Property (excluding loss brought forward from previous years) / Income from Other Sources (Excluding Winning from Lottery and Income from Race Horses)] (Please see rule 12 of the Income-tax Rules,1962) (Also see attached instructions)

ITR-1

Assessment Year Year

2011-12
PAN

First Name PERSONAL INFORMATION Flat / Door / Building Road / Street

Middle Name

Last Name Status

I - Individual Area / Locallity Date of birth (DD/MM/YYYY) 00/00/0000 Pin Code Sex (Select) M-Male

Town/City/District

State

Email Address Income Tax Ward / Circle

Mobile no

(Std code) Phone No

FILING STATUS

Employer Category (if in employment) OTH Return filed under section [Pl see Form Instruction] 11 - u/s 139(1) Date 1 2 3 4 System Calculated 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 7 8 9 10 0 0 13 14 15 Seal and Signature of Receiving Official 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Whether original or revised return?

O-Original

If revised, enter Receipt no / Date RES - Resident Residential Status 1 Income from Salary / Pension (Ensure to fill Sch TDS1) Income from one House Property 2 3 Income from Other Sources (Ensure to fill Sch TDS2)

4 Gross Total Income (1+2c) 5 Deductions under Chapter VI A (Section) 5a a 80 C 5b b 80 CCC 5c c 80 CCD 5d d 80 CCF 5e e 80 D 5f f 80 DD 5g g 80 DDB 5h h 80 E 5i i 80 G 5j j 80 GG 5k k 80 GGA 5l l 80 GGC 5m m 80 U 6 6 Deductions (Total of 5a to 5m) 7 Total Income (4 - 6) 8 Tax payable on Total Income 9 Education Cess, including secondary and higher secondary cess on 8 10 Total Tax, Surcharge and Education Cess (Payable) (8 + 9) 11 11 Relief under Section 89 12 12 Relief under Section 90/91 13 Balance Tax Payable (10 - 11 - 12) 14 Total Interest Payable 15 Total Tax and Interest Payable (13 + 14) For Office Use Only Receipt No/ Date

TAX COMPUTATION

INCOME & DEDUCTIONS

0 0 0

23 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)] Tax Deduction Income charg Name of the Total tax Account Number SI.No eable under the Employer Deducted (TAN) of the head Salaries Employer (3) (4) (5) (1) (2) 1 2 3 (Click + to add more rows to 23) TDS on Salary above. Do not delete blank rows. ) 24 Details of Tax Deducted at Source Other than Salary Tax Deduction Account Number (TAN) of the Deductor (2) Name of the Deductor (3) Total tax Deducted (4) Amount out of (4) claimed for this year (5)

SI.No

(1) 1 2 3 4

(Click + to add more rows ) TDS other than Salary above. Do not delete blank rows. )

25 Sl No 1 2 3 4 5 6

Details of Advance Tax and Self Assessment Tax Payments Date of Deposit (DD/MM/YYYY) Serial Number of Challan

BSR Code

Amount (Rs)

(Click '+' to add more rows ) Tax Payments. Do not delete blank rows. )

TAXES PAID

16 Taxes Paid a Advance Tax (from item 25) b TDS (Total from item 23 + item 24)

16a 16b

0 0

0 c Self Assessment Tax (item 25) 16c 0 Total Taxes Paid (16a+16b+16c) 17 0 Tax Payable (15-17) (if 15 is greater than 17) 18 0 Refund (17-15) if 17 is greater than 15 19 Enter your Bank Account number (Mandatory ) No Select Yes if you want your refund by direct deposit into your bank account, Select No if you want refund by Cheque 22 In case of direct deposit to your bank account give additional details MICR Code Type of Account(As applicable) 26 Exempt income for reporting purposes only (from Dividends, Agri. income < 5000) 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 2011-12 Place Date Sign here -> PAN 27 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 REFUND 17 18 19 20 21

28

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