Government of the People's Republic of Bangladesh

Natioal Board of Revenue

Income Tax Department

Acknowledgement Receipt / Certificate of Return of Income

Assessment year : 2 0 2 3 - 2 4

Name : -

NID/Passport : 0 0 0 0 0 0 0 0 0 0

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Taxes Circle - - Taxes Zone - -

Total Income Shown : ৳-

Total Tax Paid : ৳-

Serial No. of Return Register :

Volumn No. of Return Register :

Date of Return Submission : 2 6 1 1 2 0 2 3

Seal of Tax Office Signature the official receiving the return

 IT-11GA
FORM OF RETURN OF INCOME
FOR NATURAL PERSON

For Office Use

SELF
Serial No. of Return Register
ASSESSMENT
Volume No. of Return Register
U/S 180
Date of Return Submission

PART I
Basic Information

1 Assessment year : 2 0 2 3 - 2 4

2 Name :
3 Sex: Male ✘
Female Third Gender
4 TIN :
5 Taxes Circle - 6 Taxes Zone -
7 Resident Status : Resident
8 Tick on the appropriate box(es):
✘ A gazeted war-wounded freedom fighter A person with disability
Aged 65 years or more A parent/guardian of
a person with disability
9 Date of Birth [DD-MM-YYYY] :
10 If employed, employer’s name :
11 Spouse Name :
12 Spouse TIN :
13 Father’s Name :
14 Mother’s Name :
15 Present Address :

16 Permanent Address :

17 Telephone :
18 E-mail :
19 NID Number :

20 BIN :
 Statement of Accounts

Name -

TIN 0 0 0 0 0 0 0 0 0 0 0 0

Assessment year 2 0 2 3 - 2 4

Income liable to regular tax rate amount (Tk)

1 Income from Employment -
2 Income from Rent -
3 Income from Agriculture -
4 Income from Business -
5 Income from Financial Assets -
(a)
(b) -
6 Income from Other Sources -
(a) Others (Please specify) Tk.
(b) Others (Please specify) Tk. -
7 Income from Minor or Spouse (if not taxable) -
8 Taxable Income from Abroad -
Total Tk. -
Income liable to minimum tax [S163] -
1 Bank interest Tk.
2 Tk. -
3 Tk. -
Total -
Income liable to final tax settlement [S163] -
1 Interest on savings certificates [SRO253] Tk.
2 Income from Capital Gains [SRO286] Tk. -
3 Cash incentives [SRO253] Tk. -
Total Income -

Tax payable on Regular Income

Slab Rate Tax (Tk)
First 350,000 0% -
Next - 5% -
Next - 10% -
Next - 15% -
Next - 20% -
Rest - 25% -
Total tax 350,000 -
Less: Tax rebate on investment Tk. -
Tax payable Tk. -
Minimum tax -
Tax Payable -
Surcharge Tk. -
Environmental surcharge -
Total amount payable Tk. -

Tax payment
(a) Final tax settlement [S163] -
(b) Minimum tax [non adjustable] -
(c) Tax paid on vehicle
(c) Tax paid on trade license -
(d) Environmental surchage -
(e) TDS adjustable & refundable
(f) Advance tax paid [S154] -
(g) Adjustment of tax refund [S225] -
(h) Tax paid with return [S173] -
Tax payable (refundable) -

-
 PART II
Particulars of Income and Tax

TIN: 0 0 0 0 0 0 0 0 0 0 0 0

Particulars of income Amount (‌৳)

1 Income from Employment (annex Schedule 1) S 32 -
2 Income from Rent (annex Schedule 2) S 36 -
3 Income from Agriculture (annex Schedule 3) S 40 -
4 Income from Business (annex Schedule 4) S 45 -
5 Income from Capital Gains S 58 -
6 Income from Financial Assets S 62 -
7 Income from Other Sources S 66 -
8 Share of Income from Firm or AOP S 31 -
9 Income from Minor or Spouse (if not taxable) S 31 -
10 Taxable Income from Abroad S -
11 Total Income [aggregate of 1 and 10] -

Tax Computation and Payment Amount (‌৳)

12 Gross tax on Taxable Income -
13 Tax Rebate (annex Schedule 5) [S78] -
14 Net Tax after Rebate -
15 Minimum tax [S163] -
16 Tax payable [higher between 14 & 15] -
17 (a) Net wealth surcharge [Art. Ka of PII of sch-2 of FA 2023] -
(b) Environmental surcharge [PIII of sch-2 of FA 2023] -
18 Delay Interest, penalty or any other amount payable -
19 Total amount payable [16+17+18] -
20 Tax deducted/collected at source (attach proof) -
21 Advance tax paid (attach proof) [S154] -
22 Adjustment of tax refund [S225] -
23 Amount paid with return (attach proof) [S173] -
24 Total amount paid and adjusted [20+21+22+23] -
25 Deficit or excess (refundable) [19-24] -
26 Tax exempted income -

-
Place: -
Date: 2 6 1 1 2 0 2 3 -
-
 PART III
Instruction, Enclosures and Verification

TIN: 0 0 0 0 0 0 0 0 0 0 0 0

1 Instructions
a Statement of assets, liabilities and expenses (IT-10B) and statement of life style
expense (IT-10BB) must be furnished with the return unless you are exempted
from furnishing such statement(s) under section 80.

b Proof of payments of tax, including advance tax and withholding tax and the proof
of investment for tax rebate must be provided along with return.
c Attach account statements and other documents where applicable
2 If you are a parent of a person with disability, has your spouse
availed the extended tax exemption threshold? (pls select one) Yes No ✘

3 Are you required to submit a statement of assets, liabilities and

expenses (IT-10B) under section 80(1)? (pls select one) Yes ✘ No

3 Schedules annexed (select all that are applicable)

24A ✘ 24B 24C 24D 25
5 Statements annexed (select all that are applicable) IT-10B ✘ IT-10BB ✘

6 Other statements, documents, etc. attached (list all)

Verification and signature

I solemnly declare that to the best of my knowledge and belief the information given in
this return and statements and documents annexed or attached herewith are correct
and complete.

Name :
-
Signature
Date of Signature [DD-MMYYYY] Place of Signature
2 6 1 1 2 0 2 3 0
 SCHEDULE 24A
Particulars of income from employment
Employee type: ✘ Govt. & public bodies employees Non-govt. employees
[Annex this Schedule if you have income from employment]

Name : -
Assessment Year : 2 0 2 3 - 2 4

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Pay & Allowance Amount of Income Exempted Income Taxable Income

1 Basic pay - -
2 Festival allowance - -
3 Arrear pay/Special pay - -
4 Dearness/special allowance - -
5 House rent allowance - -
6 Medical allowance - -
7 Conveyance allowance - -
8 New year allowance - -
9 Education allowance - -
10 Mobile phone allowance - - -
11 Residential phone encashment - - -
12 Entertainment allowance - - -
13 Leave allowance - - -
14 Allowance for support staff - - -
15 Honorium/Rewad/Fee - - -
16 Overtime allowance - - -
17 Bonus/Ex-gratia - - -
18 Other allowances - - -
19 Employer's contribution to RPF - - -
Interest accrued on
20 Recognized PF - - -
Deemed income for transport
21 facility - - -
22 Free accommodation - - -
Employer's contribution to
23 benevolent fund - - -
24 Washing allowance - - -
Total - - -

Date of Signature (DD-MM-YYYY)

2 6 1 1 2 0 2 3 -
 SCHEDULE 24B
Particulars of income from rent
[Annex this Schedule if you have income from rent]

Name : -

Assessment Year : 2 0 2 3 - 2 4

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Location and description of the property

Total Share of the
area asessee (%)
- 100%
sft
Please tick ✘
Commercial ✘
Non-Commercia Other
Income from property Amount Amount
1 Rental value -
(a) Rent Received or Annual Value
(b) Advance Rent Received -
(c) Value of any benefit in addition to 1 & 2 -
(d) Adjusted Advance Rent -
(e) Vaccancy Allowance -
2 Allowable Deductions -
(a) Repair, Collection, etc. -
(b) Municipal Tax/Local Tax/Land Revenue -
(c) Interest paid on Loan
(d) Insurance Premium Paid -
(e) Other, if any -
3 Net Income [1-2] -
4 Taxpayer's share, if applicable 100% -

Date of Signature (DD-MM-YYYY)

2 6 1 1 2 0 2 3 -
 SCHEDULE 3
Summary of income from agriculture
[Annex this Schedule if you have income from business]

Name : 0

Assessment Year : 2 0 2 3 - 2 4

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Nature of agriculture

Summary of income from agriculture [cultivation] Amount ৳

1 Sales/Turnover
2 Cost of production [60%] -
3 Net Profit (1-2) -

Summary of income from agriculture [barga, adi, lease] Amount ৳

Sales/Turnover/Receipt -

Summary of income from agriculture [farming/nursery] Amount ৳

1 Sales/Turnover/Receipt -
2 Gross Profit Rate of GP 15% -
3 General, administrative, selling and other expenses -
4 Net Profit (2-3) -

Date of Signature (DD-MM-YYYY)

2 6 1 1 2 0 2 3 -
 SCHEDULE 4
Summary of income from business
[Annex this Schedule if you have income from business]

Name : 0

Assessment Year : 2 0 2 3 - 2 4

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Type of main business or profession

Name(s) of the business or profession
5. Address(es)
(as in trade licence)

Summary of income from business Amount ৳

1 Sales/Turnover -
2 Gross Profit Rate of GP 15% -
3 General, administrative, selling and other expenses -
4 Net Profit (2-3) -

Summary of income from profession Amount ৳

5 Receipts -
6 General, administrative and other expenses -
7 Net Profit (5-6) -

Summary of Balance Sheet Amount ৳

8 Cash in hand & at bank -
9 Inventories -
10 Fixed assets -
11 Other assets -
12 Total assets (8+9+10+11) -
13 Opening capital -
14 Net profit -
15 Withdrawals in the income year -
16 Closing capital (13+14-15) -
17 Liabilities -
18 Total capital and liabilities (16+17) -

Date of Signature (DD-MM-YYYY)

2 6 1 1 2 0 2 3 -
 SCHEDULE 5
Particulars of investment tax credit
[Annex this Schedule if you claim investment tax rebate]
(Attach the proof of claimed investment, contribution, etc.)

Name :

Assessment Year : 2 0 2 3 - 2 4

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Particulars of rebatable investment, contribution, etc. Amount

1 Life insurance premium -

2 Deposit pension scheme [Max. Tk. 1,20,000] -

3 Savings certificates [Max Tk. 5,00,000]

4 Provident fund to which Provident Fund Act, 1925 applies -

5 Benevolent fund and group insurance premium

6 -

7 -
8 Total allowable investment, contribution, etc. -
9 Investment tax rebate
(a) 3% of the total income
[excluding income libale to minimum tax.] -
(b) 15% of investment -
(c) Maximum 1,000,000

10 Amount of tax rebate [lowest among a, b, c] -

Date of Signature (DD-MM-YYYY)

2 6 1 1 2 0 2 3 -
 IT-10B
STATEMENT OF ASSETS, LIABILITIES AND EXPENSES
under section 167 of the Income Tax Act, 2023 (XII of 2023)
Tho following persons madatorily submit this form.
(a) All public servants.
(b) If the amount of Total Asset at home and abroad exceeds Taka 40,00,000.
(c) The owner of a motor car or house property in City Corporation area, or owner of asset outside Bangladesh or
a shareholder director.
(d) All non-Bangladeshi and non-resident Bangladeshi in respecto of assets located in Bangladesh.

Assessment Year Statement as on (DD-MM-YYYY)

2 0 2 3 - 2 4 3 0 0 6 2 0 2 3

Name of the Assessee : 0

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Particulars Amount (‌৳)

1 Business capital -
(a) Business capital other than 5B -
(b) Director’s shareholdings in ltd companies -
2 Non-agricultural property [sl. 2 of Schedule 25] -

3 Agricultural property [sl. 3 of Schedule 25] -

4 Financial assets value -

(a) Share, debentures, bond, securities, etc. -
(b) Savings certificate, DPS, etc.
(c) Fixed deposit, term deposits
(d) Provident fund and other funds
(e) Loans given to others (name and TIN) -
(f) Other financial assets (give details) -

5 Motor car(s) (use additional papers if more than two cars) -

Sl. Brand Name Engine(CC) Registration No Cost
i. -
ii. -
6 Gold, diamond, gems and other items [mention quantity] -

7 Furniture, equipment and electronic items -

Total of this page [carried forward to the next page] -

 Total of the previous page -
8 Assets outside Bangladesh (if any) -

9 Other assets of significant value (if any) -

-

10 Cash and fund outside business -

(a) Notes and currencies
(b) Banks, cards and other electronic cash
(c) Other deposits, balance and advance -

11 Gross wealth (aggregate of 1 to 10) -

12 Liabilities outside business -
(a) Borrowings from banks and financial institutions -
(b) Unsecured loan (mention name and TIN) -
(c) Other loans or overdrafts -

13 Net wealth (11-12) -

14 Net wealth at the last date of the previous income year
15 Change in net wealth (13-14) -
16 Other fund outflow during the income year -
(a) Expenditure and tax payments (as per IT-10BB) -
(b) Loss, etc. not mentioned in IT-10BB -
(c) Gift and contribution (name of recipient) -

17 Total fund outflow in the income year (15+16) -

18 Sources of fund -
(a) Income shown in the return -
(b) Tax exempted income and allowance -
(c) Other receipts and sources

19 Shortage of fund, if any (18-17) -

Verification and signature

I solemnly declare that to the best of my knowledge and belief the information given in this
statement and the schedule annexed herewith are correct and complete.

Date of Signature (DD-MM-YYYY) -

2 6 1 1 2 0 2 3
 SCHEDULE 25
[to be annexed to the Statement of Assets, Liabilities and Expenses (IT-10B)]

Name : 0
Assessment Year : 2 0 2 3 - 2 4

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

1 Shareholdings in limited companies as director No. of shares Value ৳

- -
- -
- -
- -
- -
Total -

2 Non-agricultural property at cost value or any advance made for such

property (description, location and size) Value ৳

-
-
-
-
-
-
Total -

3 Agricultural property at cost value (description, location and size) Value ৳

-
-
-
-
-
Total -

(Provide additional paper if necessary)

Date of Signature (DD-MM-YYYY)

2 6 1 1 2 0 2 3 -
 IT-10BB
STATEMENT OF EXPENSES RELATING TO LIFESTYLE
[under section 168 of the Income Tax Act, 2023 (XII of 2023)]

Assessment Year Statement as on (DD-MM-YYYY)

2 0 2 3 - 2 4 3 0 0 6 2 0 2 3

Name : 0

TIN : 0 0 0 0 0 0 0 0 0 0 0 0

Particulars Amount Comment

1 Expenses for food, clothing and other essentials
2 Housing expense -
3 Auto and transportation expenses -
(a) Driver’s salary -
(b) Fuel and maintenance -
(c) Other transportation
4 Household and utility expenses -
(a) Electricity
(b) Gas, water, sewerage and garbage
(c) Phone, internet, TV channels subscription
(d) Home-support staff and other expenses -
5 Children’s education expenses
6 Special expenses -
(a) Festival, party, events and gifts
(b) Domestic and overseas tour, holiday, etc. -
(c) Donation, philanthropy, etc. -
(d) Other special expenses -
7 Any other expenses
8 Total expense relating to lifestyle (1 to 7) -
9 Payment of tax, charges, etc. -
(a) Payment of tax at source, advance tax -
(b) Payment of tax, surcharge, etc. in last year
10 Total amount of expense and tax (8+9) -

Verification and signature

I solemnly declare that to the best of my knowledge and belief the information given in this
statement and the schedule annexed herewith are correct and complete.

Date of Signature (DD-MM-YYYY) -

2 6 1 1 2 0 2 3
 আইটি-৩৯

আদেশপত্র
(বিবিধ নথির জন্য)

কর সার্কে ল : 0 করবর্ষ : 2 0 2 3 - 2 4
কর অঞ্চল : 0 টিআইএন : 0 0 0 0 0 0 0 0 0 0 0 0
করদাতার নাম : 0

আদেশের ক্রমিক নম্বর ও কিভাবে ও কোন তারিখে

সংক্ষিপ্ত আদেশ, প্রয়োজনে পূর্বসূত্র উল্লেখসহ
তারিখ সম্পাদন করা হলো

করদাতা ২০২২-২৩ করবর্ষে নিম্নেবর্ণিত তথ্যাদি প্রদর্শনপূর্বক সার্বজনীন

স্বনির্ধারণী পদ্ধতিতে (৮২বিবি ধারায়) আয়কর রিটার্ন দাখিল করেছেন:

প্রদর্শিত মোট আয় : ৳-
পরিশোধিত কর : ৳-
প্রদর্শিত মোট সম্পদ : ৳-
প্রদর্শিত দায় : ৳-
প্রদির্শত নিট সম্পদ : ৳-

করদাতার ২০২২-২৩ করবর্ষের আয়কর মামলা আয়কর অধ্যাদেশ, ১৯৮৪

এর ৮২বিবি ধারায় নিষ্পত্তি করা হলো।

মাসিক কর নির্ধারণী রেজিস্টারে এন্ট্রি

ক্রমিক নং- .......................... পৃষ্ঠা ...........................

উপ কর কমিশনার
 Government of the People’s Republic of Bangladesh
Income Tax Department
National Board of Revenue

Income Tax Certificate

Particulars of taxpayer:
a) Name : -
b) Father’s Name : -
c) Mother's Name : -
d) Spouse Name : -
e) Present Address : -
-
-
f) Permanent Address : -
-
-
g) Status : Individual
h) TIN : 0 0 0 0 0 0 0 0 0 0 0 0

This is to certify that Mr./Ms .......................... is a taxpayer of Taxes Circle-..... under the

Taxes Zone-................ S/He has submitted her/his retunr showing total income of

Tk. .................... and tax paid Tk. ............... under universal self assessment system for

the assessment year 2021-22 and disposed thereof.

[name of the officer]

Official seal Deputy Commissioner of Taxes
Taxes Circle - 0
Taxes Zone - 0
Phone: -------------------