FORM A FEDERALREPUBLICOF NIGERIA RIVERSSTATE, INCOMETAX FORMRETURNOF'INCOME AND CLAIMSFORAL,I,QWANCE AND RELIEFS

20.............

c=J
INCOME TAXYEAR20"".""
(

Please quote Fileno".,:".;:."."".""..

In any col1!ll'iunication

.pATE OF ISSUE"................

""-

PURSUANTTO the provisionof...""...::'..""..""."..."..""."""..""".".".."..."."."".""..""." ":"..."..,,. TAKE NOTICEthat you are therebyrequired: (1) To prepare,in parts Band C of this form, a true and completestatementof the amountof yoyr incomefrom EACH EVERYsource,ACCRUINGin, DERIVEDfrom, BROUGHTinto or RECEIVEDin NIGERIAduring the YEAR ENDED31December20."

Computed in accordance withtheprovisions of .".""",."."

..""...

""""".".."."

and

INCOMETAX.AN6GEMENTACT, 1961, and any rulesor regulationsmade the there under (2) to preparein parts,A, D, E, and F of this form a true and completestatementof Ihe particulars required in and for such parts:

(3), to completeand sl(Jnthe DECLARATIONat the end of Ihis form and (4)' to deliverthis form, within twerity-onedilysfrom the date of its swvice upon you to the taxoffice

address (Jive below.

'

Requirements(2), (3) and (4) mustbe compliqdwith evenif thQIC is no incomefor the purposeof partBofthisform. ". ',' Before,completing thisyou shouldreadcarefullythroughthe wholeformand the explanatory notes. If you requireany furtheririformati5hyou are invitedto writeto or call at oneof the addressesgivenbelow Thereare provisionin the incomeTaxlawsfor penaltiesfor neglectingto mi:\~e ,areturnor fol making an reiurn.' .
TAX OFFICEADDRESS

PART A

PERSONAL PARTICULARS Applicable during the YEAR ENDED 31" DECEMBER, 20...

Name infull(Surname First)

StatewhetherMr/mrsor Miss

m..""""""""""""""""""""""""""""'"......................................

Whether married, single, widow orwidower

Nationality
" m " m ; """""""" "

m..................

"

'"

Address of business or employment """""""""""""""""""""""""""""',..m

m """"""""""""""""""""""""""""""""" "

"""""""""

m...........

'"......

Occupation

,...............................

Name andaddress ofemployer (ifany)

'".................

If any changein the above circumstanceshad during or sincethe YEARENDED31 DECEMI3ER 20.....

.,

Giveparticulars anddates
""""""""""""",,""""""""""""""""""""""""""""""""""""'"..."

""""""""""'"............................................ '
"""

Dateofarrival in ordeparture fromNigeria

'.......................................................... ,...........................

~
!r
~

Residence at 1 January
(Give full addre~s,.Not P.O.BOX No.). If married,state spouse's

(1) (2) (3) (4)

Name

"...........................................................................................

Businessor EmploymentAddress.......................................................................................................................... Occupation Employer ,............................................................................... ".........................................................................................................................

PARTB STATEMENTOF IN90MI; 9F T~~YE~RENDEQ,31st Decc~m?E!r ~O.....................

Eachsection of thispartshouldcompleted. IFYOUHAVE NOSUCHINCOME WRITE "NONE" AGAINSJJHESECTION INQUESTION.

ApartfromEmployment Income which istaxedon : thecurrent yearsbased; of income taxbasedQry the "income o'Hhe pro6eedlng years . exteptlng"lnthe'tase"" , ofnewordiscontinued trades, business of professions when special rules apply, , 1. Trade, Business, profession orVocation oL carried onat(stated address ofHead OffiCe andallbranches and TradeName, if different fromyouriJwn) 1 Annex copies ofaccounts forthey~arEnded 31stDecember, 20 : 2. Employment (1) Sala~.""

~
1...1..

:...;;

::.;;"

......

(2) Commissioner, Bonuses, Gratuities, etc. (3) Allowances

(Annex details of each allowance paid on your behal~

[
[,"""",'"
1
""""""':

,......
""'"

......

~-,--

3. (1) (a) Dividends fromNIGERiA COMPANIES """":"""" Enterthegross amount before deduction of, tax

(b)other Dividends".,
(2) Interest : ;

"

"
,;;',.;

1 ;',""

""""""""""""""""""""""""""""""""""""""",1","""",,"'"..,

,..,..........

(Annexa list givingdetails01eachsourceandthegross income Receivingtherelrom)

State name and address ofthe payer

4. (1) Pension from""""""""""""""""""""""""" (2) Annuity from """""""','"""""""""""""',"""'r',,'.""""w..t.,,:,,,

,.,...~......

5. Rents

,................................................................................

(Annex a listshowing foreachproperty, theamount of grossrentandor premium received therefrom andtherepairs, ratesandotherexpenses) 6. Incomereceived in or brought into Nigeriafrom sources Outside Nigeria Viz , 7. Incomein respect of other profits arising from sources not included above. (Annex detail of each sOL1fce and the incometherefrom) 8. Aggregate income fromallsources""""""""""""""""""""""""""""".',""~"""""""""" Note:Whenanysources of incomehavebeenacquired or haveceased duringtheyearended31stDecember, 20 Annexparticulars withdates.
DEDUCTIONS CLAIMED FROM INCOME OF THE YEAR ENDED 31ST DECEMBER 20.............. Any amounts claimed should be deducted in computing your income Under any of the foregoing sections of part B

,...................

N
underthe
1

9. Contributions paidin theYEARENDED 31STDecember, 20

Widows; andOrphans pension Ordinance

10. Contributions paid in the YEAR ENDED 31ST December 20 to a pension, provident or other society fund approved by

'"",

, the join Tax Board.....................................

(State name of Society of Fund)

11. Contributions paidtheYEARENDED 31STDecember,

20

totheNATIONAL PROVIDENT FUND """""""""""""""""""1"""""""""'"

Total Deduction N

PARTC 12 Residentialaddress

BENEFITS INKIND

(1)

A~. at 1stJanuary fa

(2) Changes during the,y~pr

For Official Use Only Rateable Value

"-..._..
Re~t paid Name and Address of Owner of premises

Rent paid by Employer Rent paid by Reimbursed by you 13. Name of Domestics Servant (e.g. Maids, Driver Gardeners,Watchmen, Cooks, Stewards, Cleaners, etc.) Please asterick those paid for your employer. Name ResidentialAddress i Amount paid

14.

Cost of Energy Consumed Elect(icity,. Gas, t)tcWI)erepaidbyEmploye,' N

15.

Other perquisites by employer

PART D THIS P()RT.lO~!N~F,O,~"N()!,W,!3c~~()~I;',[~TEqW~~I~fg~IA)~E~~~~,~~N~~$tl~~I SUa.M!]J~D ',,' "',', -;; ", "~'I,.' -' Assets at 31/,:12/40 ,.., IS'"

:,f7~~dp;rt~B~~"'-~,

16,
House:'

Tangibleimmovablepfpperties

",.

."'1
Cost of , -"

"

locality

-"

.. Date'bui;ing J, completed=c" ( 'i I ! i ; ; i ! .,.

(1) (2) - ...,- . -"" (3) (M I, \(W'IF

"

I
'"
,"I

Land,,-! N !

" ConstructionAcquisition

"

N
.

-...... .....'..._-- "....- ...' '_b__,_! ,-----" ,,"",...,

:; 'i, '.J ;;/1'1 ... ,,",' ,. ,,.. ..........._,-" . ..".,.."--",,,." ; "'"
"'" .. "

...,

...,., lA. ,,'m

. 'i/

I,
,,' .':(,,:, "

(5)
(6)

,"

:U pt(i, ':
Le

;;!

.
t'I',

:\ f'

,,'" ., ' "

.. '

"..."

-(7)"---'--" (8) (9) )'

"',

..

""""'0.

,.,

-(10)

" , ."..-

.. .. ", . .

r '"
,,' c;:; ,',' "f :',
"

',

1'7. Lands,
',J,"
(1) (2) (3)
f

locality

Date,AcquireQ

Cost N

,
,ii',

"
'.. " ;,
1

, "'-,"

"

(4) ('"
((11

I,
, ,

,"

" I

{7, 1
{,it

,
I ", .. ..

)) ,iil

18, Farmlands:

IOC31ily .... . ,-..

Dale AcqUIred

Cost N

Produce

.-

11'

..

"",

,
,

",

'

~ I

-- -..-,'
-,,-

(t))

, 10)

PAr 12
19. Int~rest charged on borr~wed money used produc1ng\inc6me'declared"a~ov~;'
Amount of interest paid

.'

, (1)
Amount of Purpose for Debtandrate whic:]money of interest "borrowed

and tax,litany. Deducted

111 yi,If ended .. "Tax"N -K
and .Security..forLender'sname. : 'Debt"i tjddress "".""'1"" I.

31st December 20.......,,;......,-

"

InterestT" Nu'J') ,K

,_.

I
I

-.
"
'."
,.,.

. ."", '.

- .."- ,

Iv ,
---- .

Ren
ofpI

.I+o

..,;.. .,,- ".,.. ,. .".

--.~

Narr 20,

PART E

CLAIM FD,RCAPITALALLOWANPES
Do you claim capjtaLallowance$...UmteLth!LUfth $.chdu!e to th~ !!J.~ofT1e Ta~ Management Act,' 1961 in respect of assets used for the purpose of earning

any of the income returned in P?rt.B

I

statementshowingfull particularof yourclaim

i

H"':'-'(YEfslNo)

, t

If SQ,Annex_.a

Ren!
PART F
I

!
'.
,

Renbyy'
13.

'"CLAIM FOR PERSONALHELlEFS BY'REFERENCE TO. CIRCUMSTANCES IN THE YEAR ENDED 31ST!DECEMBER 20 ._,,.0.._-

21 22.

(A)

PERSONAL ALLOWANCE Pcrsonill Allmvm{co ':.'-15'% orearned incomel'lus-N3,QOO:OOonly' . , 'ALLOWANCES FOR CHILDREN {A)""- --" c,.. ;--" An allowance of N500 is given'for each unmarried child maintained by you durino.lhe years Gilded 31 December 20 If such child was:

Uncler16at any lime during thatyear,or

(A) (6) (C)
(\lioWi1llCOS

,..

.--

Over 16 on the 1st January 20 ,. and was either receiving fulHime educ,:;tion or vms articled or indentured inall tr'iOjde'br profession in-that year.

maynol be claimedin respectof moreth~n four children.

If in respect of the same chfld '(wo person areo'eilulled,to those allowances" They may have [9 be divid.ccib~tween them.

I
Fullname of Child Dateof Birth

I
I
r

li1mepfaddress of educational establishment which oachchild attends or person to whom artic/ed or indentured

December20...............

Child's income in his orherownrightduring thoyoarended 31 (Except scholarship. incomo)

3 N

N 'N

14.

..

Where the child is not the offspring of the claimant the following particulars should be given:

15.

FULL NAME OF PARENTS

..................................................................................................................................

OCCUPATION ...........................................
OFFICE/BUSINESS ADDRESS: ,

........................................................................

~I

"............................................................................................

1I

l
~

b PARTF. Continued 23. ALLOWANCE FORDEPENDENT RELATIVES

(A) An allowancemaybe givenin respectof the amountexpendedbyyou in the yearended 31stDecember, 20".".. On the maintenance of a closerelativ",Whose incomedid not exceedN600in thatyear,if suchrelativewas: (i) (ii) (8) (C) Thewidowed mother ofyourself oryouspouse, or Incapacitated by old age or infirmityfrom maintaining himselfor herself. If t0b or more persons maintained sucha relative theallowance willbeapportioned between them TheMaximum allowance inN600 intotalforhusband andwifeandmaybesplitwhere thetotal amount spend bythemonalldependent exceeds N600

Dependents If anyother Re/ationincome Amount person Ageof has Nameandaddress shipofyou Name and the relative during to expended contributed oryour ofdependent of nature yearended onmainte-the maintenance address spouse if Relative 31st such nance inthe of widowed Decembe the yearended contributor mother infirmity 20"."....ofall during yearended 31"December state so sources 31th 20.."..."."state t1xcluding December the amountso voluntary 20"""."" contributed allowances N N
24.

""""'-'

N N

N N

ALLOWANCE FOR LIFEASSURANCE,ETC

(A) Allowances may be given in respect of the premiums paid by you in the year ended 31" December, 20".""" for the insurance of, or for a deferred annuity on, the life of your wife

orofyoursGlfsubject ofthefollowing restrictions:

(i)

Theallowance inTespect of the annualamountof eachlifeinsiJrance premium is restricted to 10percentof the capitalsumsecuredat deathexclusive of bonuses: (ii) Theaggregate amountof theaHqwal]ces forall premiums mustnotexceedone,fifth of your totalincome, and (iii) Theaggregate amount of theallowances in respect of allpremium under policies anddeferred annuity contracts andinrespect of anyamounts claimed byyou,ifyouarean. employee, under section 9 to 11of theform,mustnotexceed N2,000.
Whether on life Capital sum on death, of self or excludingany bonusOF additional benefits spouse Premiumspaid during the year ended 31st December,20.""."." (to the nearestN)

Name of Insurancecompany

CERTIFICATE/RECEIPTEVIDENCING PAYMENTMUST BE ATTACHED DECLARATIONWHICH MUST BE COMPLETEDAND SIGNED

I, ."""""."."""."""."""".".""".""""""." herebydeclaredthat partsBand C of thisformcontinuetrue and correctstatementof the amountof my income,in respectof allsources,accruingin or derivedfrom Nigena andof my incomebroughtintoor receivedin Nigeria,in respectof allsourcesoutsideNigeria,computed, to the best of my judgementand belief in accordancewith the provisionsof."."""."."""".""""."."."""""" and the INCOME TAXMANAGEMENT ACT,1961,and of any rulesmadethereunder, and that deductions claimedby me in partB of thisform havebeencomputed,as aforesaid.I furtherdeclarethatthe particulars givenby in partsA, D, E, and F of thisform and in anyAccountsor lists,etc.,Annexedby me to thisform, aretrueandcomplete.

-'

b........................... (Signatureof personmakingthe Return)

Present Private Address

..........................................................................................................

L.......

..........................................................................................................