FOR

M

SUGAM INDIAN INCOME TAX RETURN Assessment YearITR-4S Year

(Please see rule 12 of the Income-tax Rules,1962) (Also see attached instructions) 2 0 1 1 - 1 2

PER

SON

AL

INFO

RM

AT

ION

First Name Middle Name Last Name PAN

Flat / Door / Building StatusI - Individual

Road / Street Area / Locallity Date of birth (DD/MM/YYYY)00/00/0000

Town/City/District State Pin Code Sex (Select)M-Male

Email Address Mobile no (Std code) Phone No Employer Category (if in employment) OTH

Income Tax Ward / Circle Return filed under section[Pl see Form Instruction] 11 - u/s 139(1)

Whether original or revised return? O-Original

If revised, enter Receipt no / Date DateResidential Status RES - Resident

INC

OM

E &

DE

DU

CT

ION

S

1 1 0

2 Income from Salary / Pension (Ensure to fill Sch TDS1) 2 0

3Income from one House Property

3 0

4 Income from Other Sources (Ensure to fill Sch TDS2) 4 0

5 Gross Total Income (1+2+3+4) 5 06 Deductions under Chapter VI A (Section) System Calculated

a 80 C 6a 0 0b 80 CCC 6b 0 0c 80 CCD 6c 0 0d 80 CCF 6d 0 0e 80 D 6e 0 0f 80 DD 6f 0 0g 80 DDB 6g 0 0h 80 E 6h 0 0i 80 G (Eligible Amount) 6i 0 0j 80 GG 6j 0 0k 80 GGA 6k 0 0l 80 GGC 6l 0 0

m 80 U 6m 0 07 Deductions (Total of 6a to 6m) 7 0 7 08 Total Income (5 - 7) 8 0

TA

X C

OM

PUT

AT

ION 9 Tax payable on Total Income 9 0

10 Education Cess, including secondary and higher secondary cess on 9 10 011 Total Tax, Surcharge and Education Cess (Payable) (9 + 10) 11 012 Relief under Section 89 12 013 Relief under Section 90/91 13 014 Balance Tax Payable (11 - 12 - 13) 14 015 Total Interest Payable 15 016 Total Tax and Interest Payable (14 + 15) 16 0

For Office Use OnlyReceipt No/ Date

[PRESUMPTIVE BUSINESS INCOME TAX RETURN]FI

LIN

G

STA

TU

S

Income from Business (E6 of Sch BP) (Note : This value will be filled automatically from ch BP in Next Sheet. Do not enter the value here.

Seal and Signature of Receiving Official

NA

TU

RE

OF

BU

SIN

ESS

S.No. TradenameTradenameTradename

(i)(ii)(iii)

BP Computation of income from business or profession

CO

MPU

TA

TIO

N -

PRE

SUM

PTIV

E IN

CO

ME

PRESUMPTIVE INCOME UNDER 44AD

E1 Gross Turnover or Gross Receipts 0

E2 0

PRESUMPTIVE INCOME UNDER 44AEE3 0

E4 0

E5 E5 0

E6 Income Chargeable under Business (E2 + E5) E6 0

Financial Particulars of the Business

E7 Amount of Total Sundry Debtors 0E8 0E9 Amount of Total Stock-in-Trade 0E10 Amount of the cash Balance 0

Nature of business or profession, if more than one business or profession indicate the three main activities/ products

Code[Please see instruction No.9(ii)]

Total Presumptive income under 44AD (>= 8% of E1)

Note : If income is less tha 8% of Gross Receipts, it is mandatory to have a tax audit under 44AB and Regular ITR 4 form has to be filled and not this form

Presumptive Income From Heavy VehiclesPresumptive Income From Other VehiclesTotal Presumptive Income under 44AE (E3 + E4)

Note : If the profits are lower than prescribed under S.44AE or the number of vehicles owned at any time exceel 10 then the regular ITR 4 form has to be filled and not this form

FIN

AN

CIA

L

PAR

TIC

UL

AR

S

Note : For E7 to E10 furnish the information as on 31st day of March, 2011

Amount of Total Sundry Creditors

SI.No

(1) (2) (3) (4) (5)1 ###2 ###3 ###

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

###

SI.No

###(1) (2) (3) (4) (5) ###1 ###2 ###3 ###4 ###

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

TCS Details of Tax Collected at Source

SI.No

(1) (2) (3) (4) (5)1234

(Click + to add more rows ) TCS above. Do not delete blank rows. )

###IT Details of Advance Tax and Self Assessment Tax Payments ###

Sl No

###

TDS1 Details of Tax Deducted at Source from SALARY [As per FORM16 issued by Employer(s)]

Tax DeductionAccount Number

(TAN) of the Employer

Name of the Employer

Income chargeable under thehead Salaries

Total taxDeducted

TDS2 Details of Tax Deducted at Source OTHER THAN SALARY

Tax DeductionAccount Number

(TAN) of the Deductor

Name of the Deductor

Total taxDeducted

Amount out of

(4) claimed for

this year

Tax Collection Account Number Name of the

CollectorTotal taxCollected

Amount out of

(4) claimed for

this year

Sl No BSR Code Amount (Rs)

1 ###2 ###3 ###4 ###5 ###6 ###

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

######

Date of Deposit(DD/MM/YYYY)

Serial Number ofChallan

TA

XE

S PA

ID

17

a Advance Tax 17a 0b TDS 17b 0

TCS 17c 0

c Self Assessment Tax 17d 018 Total Taxes Paid (17a+17b+17c) 18 019 Tax Payable (16-18) (if 16 is greater than 18) 19 0

RE

FUN

D

20 Refund (18-16) if 18 is greater than 16 20 021 Enter your Bank Account number (Mandatory )22 No

23 In case of direct deposit to your bank account give additional detailsMICR 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

Place Date Sign here ->

PAN27 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

28

Taxes Paid PLEASE NOTE THAT CALCULATED FIELDS (IN WHITE) ARE PICKED UP FROM OTHER SCHEDULES AND ARE NOT TO BE ENTERED. For ex : The taxes paid figures below will get filled up when the Schedules linked to them are filled.

Select Yes if you want your refund by direct deposit into your bank account, Select No if you want refund by Cheque

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

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