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Information: BAR" in That Cell. For Information in NUMERICAL Box When You Do Not Want
Information: BAR" in That Cell. For Information in NUMERICAL Box When You Do Not Want
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JFN/L S,ZGF ;[,DF\ OST H~ZLIFT CMI TM VG[ TM H lJUT EZM fPHIF DFlClT XaNGF
:J~5DF\ CMI VG[ T[ BFGFDF\ SM. lJUT EZJFGL YTL G CMI TM H[ T[ ;[,DF\ cc :5[;
AFZcc S,LS SZMP HIF VF\S0FSLI DFlClT G EZJFGL T[ ;[,DF\ c0L,[8cc S,LS SZMP
Page 1 of 31
INFORMATION
GENERAL INFORMATION
Surname First Name Father's Name Grand Father's Name
Name Of Premises /
Flat/Door/Block No Road/Street/Post Office Area/Locality
Building / Village
VADODARA GUJARAT
GMSZLIFTGL S[8[UZL4 ;ZSFZL4 HFC[Z
Employer Category (Write "YES" YE
4 ;FC; S[ VgI H[ ,FU] 50T]\ CMI T[ BFGFDF\ Govt PSU
whichever applicable ) S
V\U|[ÒDF\ ccI;cc ,BMP
5 Sex D[, S[ OLD[, DF\YL ,FU] 50T]\ ,BMP FEMALE
Telephone No. with STD No. / Mobile V[;P8LP0LP G\AZ ;FY[ OMG G\AZ
7
No. 0256-2438477
VYJF DMAF., G\AZP
33 Date Of Issuing of Form No. 16 OMD" G\AZ .:I] SIF"GL TFZLB 4/30/2011
1 ST D.A. CALCULATION
Amount of D.A. Arrears (Total from First 5|YD K DF; NZdIFG D/[, DM\3JFZL
49A
6 Month ) E\yYFGF TOFJTGL ZSDP 5976.00
2 ND D.A. CALCULATION
Amount of D.A. Arrears (Total from ALHF K DF; NZdIFG D/[, DM\3JFZL
50A
Second 6 Month ) E\yYFGF TOFJTGL ZSDP 5772.00
ALHF K DF; NZdIFG D/[, DM\3JFZL
Amount deducted of "Proffetional Tax"
50B
from Second D.A. Arrears
E\yYFGF TOFJTGL ZSDDF\YL 0.00
jIJ;FIJ[ZFGL YI[, S5FTP
ALHF K DF; NZdIFG JQF" NZdIFG D/[,
Amount Paid in Cash from Second D.A.
50C
Arrears
DM\3JFZL E\yYFGF TOFJTGL 0.00
ZSDDF\YL S[XDF\ R]SJFI[, ZSDP
ALHF K DF; NZdIFG D/[, DM\3JFZL
Amount credited to "GPF" from Second
50D
D.A. Arrears E\yYFGF TOFJTGL ZSDDF\YL 5772.00
ÒP5LPV[OPDF\ HDF SZJF5F+ ZSDP
Other Arears if any give detail below
JQF" NZdIFG D//, VgI V[ZLI;" q
51A Other Arrears (Total of all other Arrears)
TOFJTGM ;ZJF/M VCL ,BM\P 36170.00
Amount deducted of "Proffetional Tax" JQF" NZdIFG D/[, VgI V[ZLI;" q
51B from Other Arrears (Total of all other TOFJTGL ZSDDF\YL jIJ;FIJ[ZFGL YI[, 0.00
Arrears) S5FTP
Amount deducted of "Group Insurance" JQF" NZdIFG D/[, VgI V[ZLI;" q
51C from Other Arrears (Total of all other TOFJTGL ZSDDF\YL ;ZSFZL lJDFGL 0.00
Arrears) GL YI[, S5FTP
Amount deducted of "Income Tax" from JQF" NZdIFG D/[, VgI V[ZLI;" q
51D Other Arrears (Total of all other TOFJTGL ZSDDF\YL VFJSJ[ZFGL YI[, 0.00
Arrears) S5FTP
JQF" NZdIFG D/[, VgI V[ZLI;" q
Amount Paid in Cash from Other
51E
Arrears (Total of all other Arrears) TOFJTGL ZSDDF\YL S[XDF\ R]SJFI[, 36170.00
ZSDP
JQF" NZdIFG D/[, VgI V[ZLI;" q
Amount credited to "GPF" from Other
51F
Arrears (Total of all other Arrears) TOFJTGL ZSDDF\YL ÒP5LPV[OPDF\ 0.00
HDF SZJF5F+ ZSDP
52 Bonus AMG; D/T]\ CMI TM T[GL ZSDP 0.00
Amount of Bonus Credited to G.P.F. (If D/[, AMG; 5{SLGL ÒP5LPV[OPDF\ HDF
53
any) SZJF5F+ ZSDP 0.00
5ZL1FF S[ VgI SM. JWFZFGL
54 Remunration(Total of all Remunrations) SFDULZL ;AA DC[GTF6]\ D/[, CMI TM 0.00
T[GM S], ;ZJF/MP
ZHF ZMS0 EyY]\ ,LW[, CMI TM T[GL
55 Leave Surrendar
ZSDP 0.00
ZHF 5|JF; ZFCTGL H[ ZSD D/[, CMI T[
56 L.T.C.( if actually enjoyed) s HM BZ[BZ 5|JF; SZ[, CMI VG[ D/[, CMI 0.00
TM HfP
Children's tution fee for one child or two JQF" NZdIFG V[S S[ A[ AF/S DF8[ EZ[,
95
Children lX1F6 OLGL ZSDP 0.00
amount of
ÒP5LPV[OPDF\
Incomtax and HDF SZJF5F+ Oct-10 0.00 6000.00 0.00
G.P.F.
ZSD 56 Nov-10 0.00 6000.00 0.00
deducted per AFH]DF\
month. NXF"JJFDF\ Dec-10 0.00 6000.00 0.00
VFJ[, K[P Jan-11 0.00 6000.00 0.00
Page 2 of 31
INFORMATION
In the table
given beside ,
enter the
###
amount of
Incomtax and
G.P.F.
deducted per
month.
Apr-10
May-10
Jun-10
###
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
ii
i 0
ii 0
iii 0
ANNEXURE - B
Details of Tax Deducted and Deposited in the Central Government Account through Challan.
( The Employer to provide payment wise details of tax Deducted and Deposited withrespect to the employee ).
1
2
3
4
Note Enter the totals of Advance tax and Self Assessment tax in Sl No. 15 a and 15c of TAXES PAID
Page 3 of 31
GRUNDY LEENABEN ALFREDBHAI
913, E-BLOCK
VADODRA
D. A. Calculation First
Period Band Pay Grade Pay Total of 2 & 3 D.A To be pay D.A paid
1 2 3 4 5 6
D. A. Calculation Second
Period Band Pay Grade Pay Total of 2 & 3 D.A To be pay D.A paid
1 2 3 4 5 6
Old 27
Diff to be Amount in Amount
pay G.P.F. in Cash
7 8 9
1494 1494 0
1494 1494 0
1494 1494 0
1494 0 1494
Old 35
Diff to be Amount in Amount
pay G.P.F. in Cash
7 8 9
1924 1924 0
1924 1924 0
1924 1924 0
5772 5772 0
913, E-BLOCK, VADODRA
INCOME YEAR :- 2010-2011 ASSESSMENT YEAR:- 2011-2012
Name of Cash
Sr.No. Description Basic Pay Grade Pay Total Sp. Pay D.A. H.R.A. M.A. W.A. T.A. C.L.A Total P.T. G.I. G.P.F. I.T.DED
the Month Allowance
1 Mar-2010 Pay 14470.00 4200.00 18670.00 125.00 5041.00 0.00 100.00 0.00 400.00 240.00 0.00 24576.00 200.00 100.00 7054.00 0.00
2 Apr-2010 Pay 14470.00 4200.00 18670.00 125.00 5041.00 0.00 100.00 0.00 400.00 240.00 0.00 24576.00 200.00 100.00 6000.00 0.00
3 May-2010 Pay 14470.00 4200.00 18670.00 125.00 6535.00 0.00 100.00 0.00 400.00 240.00 0.00 26070.00 200.00 100.00 6000.00 0.00
4 Jun-2010 Pay 14470.00 4200.00 18670.00 125.00 6535.00 0.00 100.00 0.00 400.00 240.00 0.00 26070.00 200.00 100.00 6000.00 0.00
5 Jul-2010 Pay 15040.00 4200.00 19240.00 125.00 6734.00 0.00 100.00 0.00 400.00 240.00 0.00 26839.00 200.00 100.00 6000.00 0.00
6 Aug-2010 Pay 15040.00 4200.00 19240.00 125.00 6734.00 0.00 100.00 0.00 400.00 240.00 0.00 26839.00 200.00 100.00 6000.00 0.00
7 Sep-2010 Pay 15040.00 4200.00 19240.00 125.00 6734.00 0.00 100.00 0.00 400.00 240.00 0.00 26839.00 200.00 100.00 6000.00 0.00
8 Oct-2010 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
9 Nov-2010 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
10 Dec-2010 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
11 Jan-2011 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
12 Feb-2011 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
13 D.A. Arrears 1 5976.00 5976.00 0.00 0.00 4482.00 0.00
14 D.A. Arrears 2 5772.00 5772.00 0.00 0.00 5772.00 0.00
15 Other Arrears 36170.00 36170.00 0.00 0.00 0.00 0.00
16 Bonus 0.00 0.00 0.00
17 Remunretion 0.00 0.00
18 Leave Surrender 0.00 0.00
19 L.T.C. 0.00 0.00
20
TOTAL 178200.00 50400.00 228600.00 1500.00 98392.00 0.00 1200.00 0.00 4800.00 2880.00 36170.00 373542.00 2400.00 1200.00 83308.00 0.00
ANY OTHER INCOME (ACCEPT SALARIES TO BE DECLARED SHOW HERE ( LIKE INTEREST,DIVIDEND, ETC)
Bank Intrest 0.00 L.I.C. Jivandhara 0.00
N.S.C. Interest ( Series-8) 0.00 L.I.C. Jivanakshay 0.00
N.S.S.( Scheme-1987) 0.00 E.L.S.S. 0.00
N.S.S. Interest ( Scheme-1992) 0.00 Tution Income 0.00
Income from Minor Children 0.00 Any other Income 0.00
Jivansuraksha Pension Fund 0.00 Income from House Property. 0.00
Contribution of Central Government 0.00
DESIGNATION : SR.CLERK
(c) Under Rule 10(14)(ii)Rule 2,BB(ii)TRANS.ALLOWANCE,( 1->100 % Upto limit of Monthly Rs. 4800.00
Rs. 800/-) And ( 2->100 % Upto limit of Monthly Rs. 1600/- For P.H. Employee)
(d) Total of (a)+(b)+(c) ( Allowances to be deducted Under Rule 10) Rs. 4800.00
"(3) Deduction under rule As per Rule 16(3), PROFESSIONAL TAX ( 100 % ) Rs. 2400.00
"(4) Deduction under rule As per Rule 16(5), L.T.C. Rs. 0.00
A Remaining Salary Income (Column : 1-2(d)-(3) Rs. 366342.00
"(3) As per Rule 80-CCD. Investment in any Pension Scheme of Central Government Rs. 0.00 Rs. 0.00
( Concerned with new employee employed after 01-01-2004)
Page 7 of 31
STATEMENT OF INCOME TAX
"(4) As per Rule 80-C ( Limit Upto Rs. 110000.00) but less of 80-CCC & 80-CCD
(i) G.P.F./ C.P.F. Rs. 83308.00
(ii) P.P.F. Rs. 0.00
(iii) L.I.C. Premium Rs. 3892.00
(iv) P.L.I. Premium Rs. 0.00
(v) Group Insurance Rs. 1200.00
(vi) Investment in U.L.I.P. Rs. 0.00
(vii) Post Office C.T.D. ( 10 Or 15 Year ) Rs. 0.00
(viii) N.S.C. (Series - 8 ) Rs. 0.00
(ix) N.S.C.Interest as Reinvestment Rs. 0.00
(x) H.B.A.Principal Rs. 72038.00
(xi) N.S.S. (Scheme-1992) Rs. 0.00
(xii) L.I.C. Jivandhara Premium Rs. 0.00
(xiii) L.I.C. Jivanakshay Premium Rs. 0.00
(xiv) E.L.S.S. Unit Investment Rs. 0.00
(xv) Investment in Share or Debenture of Infrastructure,Power or Teli Communication Company. Rs. 0.00
(xvi) Investment in Home Loan Scheme Rs. 0.00
(xvii) Tution fee paid for children Rs. 0.00
(xviii) Other elligible if any Rs. 0.00
Total of (i) TO (xviii) Rs. 160438.00
Description Invesment Eligible
Total of ( 80-C ) + ( 80-CCC ) + ( 80-CCD ) Rs. 160438.00
"(5) Net Deduction under section 80-CCE Rs. 100000.00
"(6) Under section 80-D, Mediclaim Premium ( Upto Rs. 15,000.00, but Rs.20,000.00 for Rs. 0.00 Rs. 0.00
ceniyor citizen )
"(6) Under section 80-D, Mediclaim Premium for parents ( Upto Rs. 15,000.00 but Rs. 0.00 Rs. 0.00
Rs.20,000.00 If they are ceniyor citizen)
"(7) Under section 80-DD, Medical Expenses done for P.H. dipendable personal relative Rs. 0.00 Rs. 0.00
"(8) Under section 80-DDB,Medical Expense done for Dangerous deases like Cancer (Upto Rs. Rs. Err:504
0.00
Rs. 40000.00). If the person is senior citizen, than upto Rs. 60000.00.
"(9) Under section 80-E,Intrest of loan taken for higher Education for 7 year from starting Rs. 0.00 Rs. 0.00
"(10) Under section 80-CCF, Investment in Infrastructure bond notified by central Rs. 0.00 Rs. 0.00
government
"(11) Under section 80-G,Donation like C.M. Fund, P.M. Fund or other Donations Rs. 0.00 Rs. 0.00
"(12) As Per Rule 80-U,Special Deduction to P.H. & Blind employee ( Upto Rs. 50,000/- ) Rs. 0.00 Rs. 0.00
"(13) Total of amount to be deducted of Division (C) [(1)+(5)+(6)+(7)+(8)+(9)+(10)+(11) Rs. Err:504
Less Income [ Division : B - Division : C(12) ] Rs. Err:504
Remaining Amount Rounded to Rs.10/- ( Ten) Rs. Err:504
DIivision : E Calculation of Income Tax
General Women Ciniyer Citizen Tax Amount Tax
"(1) Upto Rs. 160000/- Upto Rs. 190000/- Upto Rs. 240000/- 0% Err:504 Rs. 0.00
"(2) 160001 TO 500000/- 190001 TO 500000/- 240001 TO 500000/- 10% Err:504 Rs. Err:504
"(3) 500001 TO 800000/- 500001 TO 800000/- 500001 TO 800000/- 20% Err:504 Rs. Err:504
"(4) 800001/- to onward 800001/- to onward 800001/- to onward 30% Err:504 Rs. Err:504
Total amount of Tax : Rs. Err:504
Adjustment of Income Tax
Amount of Income Tax Rs. Err:504
2 % education surcharge + 1 % SEC & HSEC surcharge Rs. Err:504
Less Relief Under section 89 0.00
Net amount of Income Tax Rs. Err:504
Details of Income Tax paid or to be pay
1 Recovered Upto JANU-2011 Rs. 0.00
2 To be recovered from pay of FEB-2011 Rs. Err:504
3 Recovered from pay of FEB-2011 Rs. 0.00
4 Total Income-Tax paid Rs. 0.00
Page 8 of 31
STATEMENT OF INCOME TAX
Certificate by employee
This is to certify that the information given in this statement is true and mistake
less.
Certificate by office
This is to certify that the information given in this statement compared with office
record as well as documents presented by employee and found correct.
Page 9 of 31
FORM NO.:-16
[See Rule 31(1)(a)]
PART-A
Certificate under Section 203 of the Income-Tax act,1961 for the tax deducted at source on "SALARIES".
Name and Address of the Employer Name & Designation of the Employee
FROM TO
Address
2011-2012
City Pin Code
4/1/2010 3/31/2011
Summary of tax deducted at source
Recipt Numbers of original statement of Amount of tax deduction in Amount of tax deposited remitted
Quarter
TDS under sub-section (3) of section 200 respect of the employee in respect of the employee
Details of salary paid and any other income and tax deducted.
(b) Value of perquisites under section 17(2) ( as per Form No. 12BB, whereever applicable Rs.
Profits in lieu of salary under section 17(3) ( as per Form No. 12BB, whereever
(c) Rs.
applicable
Income Rs.
0.00
9 Deduction under Chapter VI-A Rs. Gross Amount Rs. Deductible Amount
Note:2 Aggregate amount deductible under the three Section i.e.80 C, 80CCC and Section 80 CCD shall not be exceed One Lakh rupees.
( B ) Other Section ( e.g. 80 E, 80 G etc) under chapter VI-A Gross Amount Qulifting Amount Deductible Amount
(i) Section - 80 D Rs. 0.00 Rs. 0.00 Rs. 0.00
"FORM-16"
Page 10 of 31
( viii ) Section 24 ( 2 ) HBA intrest Rs. 8649.00 Rs. 8649.00 Rs. 8649.00
"FORM-16"
Page 11 of 31
10 Aggregate of deductible amount under chapter VI-A Rs. Err:504
Verification
I C.P.PATEL son / daughter of 0 Working in the
capacity of Administrative Officer (designation ) do hereby certify that a sum of Rs. 0.00
[ Rs NIL ( in words ) ] has been deducted and deposited to the credit of the
Central Government,. I further certify that the information given above is true, complete and correct and is based on the books of account documents ,TDS statement, TDS
deposited and other available records.
Place : VADODRA
Dated: 4/30/2011 Signature of the person responsible for deduction of Tax.
ANNEXURE - A
Details of Tax Deducted and Deposited in the Central Government Account through book entry.
( The Employer to provide payment wise details of tax Deducted and Deposited withrespect to the employee ).
2
3
4
5
7
8
9
10
11
12 0.00
13 0.00
15 1 In the column for TDS, give total amount for TDS,Surcherge ( if applicable) and education cess.
ANNEXURE - B
Details of Tax Deducted and Deposited in the Central Government Account through Challan.
( The Employer to provide payment wise details of tax Deducted and Deposited withrespect to the employee ).
Note : 1 In the column for TDS, give total amount for TDS,Surcherge ( if applicable) and education cess.
"FORM-16"
Page 12 of 31
INDIAN INCOME TAX RETURN Assessment Year
SAR
FORM
AL-II [For Individuals having Income from Salary / Pension / Income from One House Property
(ITR- ( exluding loss brought forward from previous years ) /
1) Income from other Sources ( Excluding Winning from Lottery and Income From Race Horses)]
2 0 1 1 - 1 2
(Please see Rule 12 of the Income-tax Rules,1962)(Also see attached instructions)
3 Income chargeable under the Head ‘Other Sources’ ( enter -ve sign in case of loss if any ) 3 0.00
3 Gross Total Income ( 1 + 2 + 3 ) 4 357693.00
5 Deductions under chapter VI A (Section)
a 80CCE 100000.00 e 80E 0.00 i 80GG 0.00
b 80D 0.00 f 80CCF 0.00 j 80GGA 0.00
c 80DD 0.00 g 80G 0.00 k 80GGC 0.00
d 80DDB Err:504 h 80U 0.00 l
6 Deductions ( Total of 5a to 5l ) 6 Err:504
7 Total Income ( 4-6m ) 7 Err:504
8 Tax Payable on Total Income 8 Err:504
TAX COMPUTATION
Receiiptt No
Date
16 Taxes Paid
a Advance Tax (from item 25) 16a 0.00
TAXES PAID
23 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]
Sr Tax Deduction Account Number (TAN) of the Name and address of the Income Tax payable
Deduction under Total tax Tax payable
chargeable under ( Incl. education
No. Employer Employer Chapter VI-A deducted /refundable
TDS ON SALARY
i
0
ii
0
iii
0
Note Enter the totals of column (7) of 23 and column (7) of 24 in Sl No. 17 of TAXES PAID
26 Other Information (transactions reported through Annual Information Return) (Please see instruction number-9(ii) for code)
Sr. Code Amount (Rs) Sr. Code Amount (Rs) Sr. Code Amount (Rs)
A 001 D 004 G 007
B 002 E 005 H 008
C 003 F 006
27 Exempt income any for reporting purposes ( from Dividend, Capital gains etc) 27
VERIFICATION
solemniy declare that to the best of my knowledge and belief, the /information
I, GRUNDY LEENABEN ALFREDBHAI son daughter ofgiven in the return
GRUNDY
thereto isALFREDBHAI THOMASand that the
correct and complete
amount of total income and other particulars shown therein are truly stated and are in accordance with the provisions of the Income-tax
Act,2011-2012
1961, in respect of income chargeable to Income-tax for the previous year relevant to the Assessment Year
28 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
29 If TRP is entitled for any reimbursement from the Government, amount thereof (to be filled by TRP) 29
Government of India
Name PAN
GRUNDY LEENABEN ALFREDBHAI A C B P G 6 5 0 1 F
Flat/Door/Block No Name Of Premises/Building/Village
W-3 OFFICER COLONY
Road/Street/Post Office Area/Locality
B/H CURKIT HOUSE
Town/City/District State
VADODARA GUJARAT
7 Taxes Paid
a Advance Tax 7a 0.00
b TDS 7b 0.00
c TCS 7c 0.00
d Self Assessment Tax 7d
d Total Taxex Paid (7a + 7b + 7c + 7d ) 7e 0.00
8 Tax Payable ( 6 - 7d ) 8 Err:504
9 Refund ( 7e - 6 ) 9 Err:504
Date
INDIAN INCOME TAX RETURN Assessment Year
FORM ITR-1 [For Individuals having Income from Salary / Pension / Family Pension & Interest]
(Please see Rule 12 of the Income-tax Rules,1962) 2 0 1 1 - 1 2
(Also see attached instructions)
Residential Status (Tick) Ö Resident Non-Resident Resident but Not Ordinarily Resident
b Surcharge on 9a 9b 0.00
Education Cess,including secondary and higher education cess on
c
( 9a+9b )
9c Err:504
Receiiptt No
Date
15 Taxes Paid
a Advance Tax (from item 23) 15a 0.00
TAXES PAID
b TDS (column 7 of item 21 +column 7 of item 22) 15b 0.00
c Self Assessment Tax (from item 23) 15c
d Total Taxes Paid (15a+15b+15c) 15d 0.00
16 Tax Payable (14-15d) (Enter if 14 is greater than 15d, else leave blank) 16 Err:504
17 Refund (15d-14) (enter if 15d is greater than 14, also give Bank Account details below) 17 Err:504
REFUND
21 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]
Tax
Sr Tax Deduction Account Number (TAN) of the Name and address of the Income Deduction
payable( Incl. Total tax Tax payable
chargeable under under Chapter
No. Employer Employer surch. and edu. deposited /refundable
the head Salaries VI-A
cess)
TDS ON SALARY
i DY.DIRECTOR, 913, E-
366342 Err:504 Err:504 0 Err:504
BLOCK, VADODRA
A A A L D 0 2 5 1 A
ii
, , 0
22 Details of Tax Deducted at Source on Interest [As per Form 16 A issued by Deductor(s)]
Amount out
Date of
Sr Tax Deduction Account Number (TAN) of the Name and address of the of (6)
Amount paid / Credit Payment / Total tax deposited
No. Deductor Deductor claimed for
Credit
this year
TDS ON INTEREST
ii
0
iii
0
Note Enter the totals of column (7) of 21 and column (7) of 22 in Sl No. 15b of TAXES PAID
24 Other Information (transactions reported through Annual Information Return) (Please see instruction number-9(ii) for code)
Sr. Code Amount (Rs) Sr. Code Amount (Rs) Sr. Code Amount (Rs)
a 001 d 004 g 007
b 002 e 005 h 008
c 003 f 006
VERIFICATION
I, GRUNDY LEENABEN ALFREDBHAI son / daughter of GRUNDY ALFREDBHAI THOMAS
solemniy 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
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) 28
Government of India
Name PAN
Town/City/District State
VADODARA GUJARAT
14 Taxes Paid
Date
INDIAN INCOME TAX RETURN Assessment Year
FORM ITR-2 [For Individuals and HUFs not having Income from Bussiness or Profession]
(Please see Rule 12 of the Income-tax Rules,1962) 2 0 1 1 - 1 2
(Also see attached instructions)
Residential Status (Tick) Ö Resident Non-Resident Resident but Not Ordinarily Resident
( a ) Name of representative
( b ) Address of representative
a Short term
Receiiptt No
Date
Page 21
4 Income from other sources
a from sources other than from owning race horses ( 3 of Schedule OS) 4a 0.00
b from owning race horses ( 4c of Schedule OS ) ( enter nil if loss) 4b 0.00
c total ( a + b ) ( enter nil if 4c is a loss) 4c 0.00
5 Total ( 1 + 2 + 3c + 4c ) 5 366342.00
6 Losses of current year set off against 5 ( total of 2vi and 3 vi of schedule CYLA ) 6 -8649.00
7 Balance after set off current year losses ( 5 - 6 ) ( also total of column of 4 of schedule CYLA ) 7 357693.00
8 Brought forward losses set off against 7 ( 2vi of shedule BFLA ) 8 0.00
9 Gross Total income ( 7 - 8 ) ( also 3vii of shedule BFLA ) 9 357693.00
10 Deduction under chapter VI - A ( n of shedule VIA ) 10 Err:504
11 Total income ( 9 - 10 ) 11 Err:504
12 Net agricultural income / any other income for rate purpose ( 4 of schedule El ) 12 0.00
13 Aggregate income ( 11 +- 12 ) 13 Err:504
14 Losses of current year to be carried forward ( total of row xi of schedule CFL ) 14 0.00
Part B - TTI Computation of tax liability on total income
1 Tax Payable on Total Income
a Tax at normal rates 1a Err:504
b Tax at special rates ( 11 of schedule SI ) 1b
c Tax Payable on Total Income ( 1a + 1b ) 1c Err:504
2 Surcharge on 1c 2 0.00
COMPUTATION OF TAX LIABILITY
13 Do you want your refund by Ö cheque, or deposited directly into your bank account? (tick as applicable)
14 In case of direct deposit to your bank account give additional details
MICR Code Type of Account (tick as applicable) Ö Savings Current
VERIFICATION
I, GRUNDY LEENABEN ALFREDBHAI son / daughter of GRUNDY ALFREDBHAI THOMAS
solemniy declare that to the best of my knowledge and belief, the information given in the return and shedules 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
provision of the Income-tax Act, 1961, in respect of income chargeble to Income-tax for the previous year relevent to the
Assessment Year 2011-2012
Page 22
15 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 16
1 Salary ( Excluding all allowanse, prequisites & profit in lieu of salary ) 1 366342.00
2 Allowances exempt under section 10 2 7200.00
3 Allowances not exempt 3
4 Value of perquisites 4
5 Profit in lieu of salary 5
6 Income chargeble under the Head "Salaries" ( 1+3+4+5 ) 6 366342.00
Schedule - HP Details of income from House Property ( Please refer to instructions. )
Address of property 1 Town / City State PIN code
1
W-3, OFFICER COLONY, B/H CURKIT HOUSE VADODARA GUJARAT
Annual letable value / rent received or receivable ( Higher if let out for whole of the year,
a 1a 0.00
lower if let out for part of the year. )
b The amount of rent which cannot be realized 1b
c Tax paid to local authorities. 1c
d Total ( 1b + 1c ) 1d 0.00
e Balance ( 1a - 1d ) 1e 0.00
f 30 % of 1e 1f 0.00
g Interest payable on borrowed capital 1g 8649.00
h Total ( 1f + 1g ) 1h 8649.00
HPUSE PROPERTY
Annual letable value / rent received or receivable ( Higher if let out for whole of the year,
a 2a
lower if let out for part of the year. )
b The amount of rent which cannot be realized 2b
c Tax paid to local authorities. 2c
d Total ( 2b + 2c ) 2d
e Balance ( 2a - 2d ) 2e
f 30 % of 2e 2f
g Interest payable on borrowed capital 2g
h Total ( 2f + 2g ) 2h
i Income from house property 2 ( 2e - 2h ) 2i
3 Income under the head " Income from house property "
a Rent of earlier years realized under section 25 A / AA 3a
b Arrears of rent received during the year under section 25 B after deducting 30 % 3b
c Total ( 3a + 3b + 1i + 2i ) 3c -8649.00
NOTE > Please include the income of the specified person referred to in Schedule SPI while computing the income under this head.
Page 23
iv Total ( i +ii + iii ) biv
c Balance ( 2a - biv ) 2c
Loss if any, to be ignored under section 94(7) or
CAPITAL GAINS
d 2d
94(8) ( enter positive values only. )
e Exemption under section 54B/54D 2e
f Short term capital gain ( 2c - 2d - 2e ) 2f
3 Amount deemed to be short term capital gains under section 54B/54D/54EC/54ED/54G/54GA A3
4 Total short term capital gain ( 1 + 2f + A3 ) A4
5 Short term capital gain under section 111A included in 4 A5
6 Short term capital gain other than referred to in secion 111A (A4 - A5 ) A6
B Long term capital gains
1 Assets in case of non-resident to which first proviso to section 48 applicable 1
2 Other assets where proviso to section 112 (1) not applicable
a Full value consideration 2a
b Deduction under section 48
i Cost of acquisition after indexation bi
ii Cost of Improvement after indexation bii
iii Expenditure on transfer biii
iv Total ( bi +bii + biii ) biv
c Balance ( 2a - biv ) 2c
Exemption under sections
d 54/54B/54D/54EC/54F/54G/54GA 2d
e Net balance ( 2c - 2d ) 2e
3 Other assets where proviso to section 112 (1) is applicable
CAPITAL GAINS
Page 24
Schedule - CYLA Details of Income after Set off of current year losses.
Sr.No. Head / Sources of Income Income of current year ( Fill House property loss of the Other sources loss ( other than Current year's Income
this column only if income is current year set off loss from race horses ) of the remaining after set off
zero or positive ) current year set off
CURRENT YEAR LOSS ADJUSTMENT
1 2 3 4=1-2-3
Lose to be adjusted
ii House Property
Schedule - BFLA Details of Income after Set off of Brought Forward losses of earlier years.
Sr.No. Head / Sources of Income Income after set off, if any, of current Brought forward loss set off Current year's Income remaining after set
year's losses as per 4 of schedule CYLA off
1 2 3
i Salaries
ii House Property
iii Short term capital gain
iv Long term capital gain
Other sources ( including
v profit from owning race
horses )
ii 2001-02
iii 2002-03
iv 2003-04
v 2004-05
vi 2005-06
vii 2006-07
viii 2007-08
ix Total of earliar year losses
x Adjustment of above losses in
Schedule BFLA
xi 2008-09 ( Current year losses )
Total loss Carried Foraward to
xii future years
Page 25
Income of specified persons(spouse, minor child etc) includable of the assessee ( income
Schedule - SPI of the minor child to be included after Rs. 1,500 per child)
Sr.No. Name of person PAN of person (optional) Relationship Nature of Income Amount(Rs.)
1
2
3
Income chargeble to Income tax at special rates [ Please see instruction No.9(iii) for
Schedule - SI section code and rate of tax]
Sr. Section Special rate Income Tax thereon Sr. Special rate Income Tax thereon
No. code Ö (%) i ii No.
Section code Ö
(%) i ii
SPECIAL RATE
1 6
2 7
3 8
4 9
5 10
11 Total ( 1ii to 10 ii )
2 Dividend income 2
3 Long term capital gains from transaction on which Securities Transaction Tax is paid 3
4 Neat Agriculture income / any other income for rate purpose 4
5 Others, including exempt income of minor children 5
6 Total ( 1 + 2 + 3 + 4 + 5 ) 6
Other Information (transactions reported through Annual Information Return)
Schedule - AIR [ Please see instruction No.9(ii) for code ]
SI Code of transaction Ö Amount ( Rs. ) SI Code of transaction Ö Amount ( Rs. )
1 001 5 005
2 002 6 006
3 003 7 007
4 004 8 008
Schedule - IT Details of Advance Tax and Self Assessment Tax Payments of Income - tax.
Sl Date of Deposit Serial Number of
Name of Bank & Branch BSR Code Amount (Rs)
No. (DD/MM/YYYY) Challan
TAX PAYMENTS
i
ii
iii
iv
v
NOTE > Enter the totals of Advance tax and Self Assessment tax in Sl No. 9a and 9c of Part-B TTI.
Schedule - TDS1 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]
Deduction Tax payable( Total
Income Tax
Sr Tax Deduction Account Number (TAN) of the Name and address of the chargeable under Incl. surch. tax
under payable
No. Employer Employer the head Salaries Chapter VI- and edu. deposite
/refundable
A cess) d
TDS ON SALARY
i DY.DIRECTOR, 913, E-
357693 Err:504 Err:504 0 Err:504
BLOCK, VADODRA
A A A L D 0 2 5 1 A
ii
, , 0 0 0
Schedule - TDS2 Details of Tax Deducted at Source on Income [As per Form 16 A issued by Deductor(s)]
Amount out
Date of
TDS ON OTHER INCOME
Sr Tax Deduction Account Number (TAN) of the Name and address of the Total tax of (6)
Amount paid / Credit Payment /
No. Deductor Deductor deposited claimed for
Credit
this year
(1) (2) (3) (4) (5) (6) (7)
i
0
ii
0
Page 26
TDS ON
0
NOTE > Enter the total of column (7) of Schedule TDS-1 and column (7) of Schedule-TDS-2 in 9 (b) of Part B - TTI.
Government of India
Name PAN
A C B P G 6 5 0 1 F
Flat/Door/Block No Name Of Premises/Building/Village
Town/City/District State
VADODARA GUJARAT
16 Refund (14c-13) 16
Page 27
Date
Page 28
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~FPZZ$_qv D/X[P VF ZLT[ H]NF H]NF S], !_ V[GPV[;P;LPGF jIFHGL U6TZL V[SL
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08-5-1989 TO 31-12-1998 A D1 5000.00
01-01-1999 TO 14-01-2000 B D2 5000.00
15-01-2000 TO 28-02-2001 C D3 5000.00
01-03-2001 TO 28-02-2002 D D4 5000.00
01-03-2002 TO 28-02-2003 E D5 5000.00
01-03-2003 TO ONWARDS F D6 5000.00
B4 0.00
C3 0.00
D2 0.00
E1 0.00
lS\DTGF V[GPV[;P;LP G]\ K99F
!q!Zq!))( JrR[ VFJ[ K[PT[GL
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jIFHGL U6TZL V[SL
D/X[P
486.00 4.86
533.50 5.335
585.50 5.855
642.50 6.425
705.00 7.05
773.50 7.735
0.00
0.00
0.00
0.00
3726.00
A1 124.00
A2 139.00
A3 156.00
A4 175.00
A5 197.00
A6 224.00
B1 118.30
B2 132.30
B3 148.00
B4 165.40
B5 185.10
B6 206.90
C1 113.00
C2 125.80
C3 140.00
C4 155.80
C5 173.50
C6 193.10
D1 97.20
D2 106.70
D3 117.10
D4 128.50
D5 141.00
D6 154.70
E1 92.00
E2 100.50
E3 109.70
E4 119.80
E5 130.90
E6 142.90
F1 81.60
F2 88.30
F3 95.50
F4 103.30
F5 111.70
F6 120.80