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    INCOME - TAX STATEMENTFOR THE FINANCIAL YEAR 2009-2010

    Name of the Employee DIVYESH SHAMBHUBHAI ANSODARIYA

    Designation ASSISTANT TEACHER D.O.B 29.3.1979Office Name KHADKHAD PRIMARY SCHOOL

    Office Address KHADKHAD Ta. VADIA Dist. AMRELIINCOME TAX PERMANENT A/C No. (PAN) AFSPA6876M

    Rs. Rs. Rs.1. Estimated Gross Income for the financial

    year 2008-2009 Basic Pay 105763Grade pay 28600

    Transport 0Medical 1200

    D.A. 39594H.R.A. 12360

    Head Allow. 0OTHER 0

    TOTAL 187517

    2. i) Whether living in a rented house and actuallyincurring expenditure on rent.

    ii) Deduction in respect of H.R.A. exemptiona) Actual H.R.A. receivedb) 10% of salaryc) Actual rent paidd) Excess rent paid above 10% of salarye) 40% of salary

    f) Least of a,d,eiii) H.R.A. Deduction U/S 10 (13A) 0

    3. Balance [ 1 - 2 (iii) ] 187517

    4. LESS: Professional Tax U/S 16 (iii) 2600

    5. Gross Total Income [ 3 - 4 ] 184917

    6. Other income:- 1. a/c interest 02. other 0

    184917

    8. Deductions under chapter VI A0 0

    ( Rs. 15000/- if beneficiary is a senior citizenwith age 65 years & above ) U/S 80 D

    b) Expenditure on a handicapped dependant, 0 0max. Rs. 50000/- at flat rate ( Rs. 75000/- incase of dependent with severe disability )U/S 80 DD

    c) Actual expenditure on assessee / dependant 0 0patient for treatment of specified diseases

    limited to Rs. 40000/- ( Rs. 60000/- in caseof senior citizen, 65 yrs & above) U/S 80 DDB

    d) R li f t h i ll h di d / t ll 0 0

    7. Net income [ 5 + 6 ]GROSS

    AMOUNTQUALIFYAMOUNT

    a) Medical insurance premium up to Rs. 10000/-

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    severe disability, Rs. 75000/- ) U/S 80 U

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    e) Repayment of Educational loan of assessee, 0 0

    max. limited to Rs. 40000/- ( loan & interest )U/S 80 Ef) Interest on House Loans, max. Rs. 30000/- 0 0

    for loans before 01-04-1999 & Rs. 150000/-for loans on or after 01-04-1999.

    g) Contribution to specified funds U/S 80 G 0 0TOTAL 0 0

    09. Total income [ 7 - 8 (h) ] 18491710. A) Specified savings qualifying for deduction U/S 80 C

    a) G.P.F. 74181b) A.P.G.L.I. 0c) L.I.C. & P.L.I. (Salary deduction) 0d) G.I.S. 1200e) P.P.F. 0f) ULIP / LIC, Mutual Funds etc. 0g) N.S.C. 0

    h) Interest on N.S.C. 0i) House loan repayment. 0j) Tuition fees paid on children's education 0k) L.I.C. Premiam paid 0l) P.L.I. Premiam paid 0

    m) Tax Saving Infrastructural Bonds 00

    TOTAL [ A + B ] 7538175381

    11. a) Total Taxable Income [ 9 - 10 (n) ] 109536

    10954012. a) Income Tax on income at S.No. 11 (b) 0Up to Rs 160000/- N I L

    Rs. 160001/- to 300000/- 10% of amount exceeding 150000/-

    Rs. 300000/- to 500000/- Rs. 15000+20% of amount exceeding 300000/-

    Rs. 500000/- & above Rs. 55000+30% of amount exceeding 500000/-

    b) Surcharge @ 10% of tax payable for income above Rs. 1000000/- 0c) Educational cess @ 3% of tax payable on (a+b) 0

    013. a) LESS : Relief on arrears U/S 89 (i) 0

    0

    14. a) LESS: Tax already deducted up to Dec, 09 0b) Tax to be deducted from Jan, 09 onwards 0

    In Jan,2009 In Feb,2009Rs. 0 Rs. 0TAX TO BE PAID THROUGH CHALLAN Rs. 0

    CERTIFICATE BY EMPLOYEE

    THIS IS TO CERTIFY THAT INFORMATION IN THIS STATEMENT IS CORRECT AND MISTAKLESS.

    Date :-Place :- KHADKHAD Signature of Employee

    CERTIFICATE BY OFFICE

    h) TOTAL QUALIFYING AMOUNT (DEDUCTION)

    B) Contributions to L.I.C. & other pension schemes U/S 80 CCC

    n) TOTAL QUALIFYING AMOUNT

    b) Total Taxable Income (rounded to nearest 10/-)

    d) Gross income tax [ a + b + c ]

    b) Tax Liability during 2008-09 [ 12 (d) - 13 (a) ]

    THIS IS TO CERTIFY THAT INFORMATION IN THIS STATEMENT COMPAIRED WITH OFFICE RECORD

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    Date :-Place :- KHADKHAD Signature of Head of Office

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    TOTAL [ A + B ] 75381n) TOTAL QUALIFYING AMOUNT 75381

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    13. a) Total Taxable Income [ 11 - 12 (n) ]b) Total Taxable Income (rounded to nearest 10/-)

    14. a) Income Tax on income at S.No. 13 (b)b) Surcharge @ 10% of tax payable for income

    above Rs. 1000000/-c) Educational cess @ 3% of tax payable on (a+b)

    d) Gross income tax [ a + b + c ]

    15. a) LESS : Relief on arrears U/S 89 (i)b) Tax Liability during 2007-08 [ 14 (d) - 15 (a) ]

    16. LESS : TAX DEDUCTED AT SOURCE

    17. TAX PAYABLE

    DETAILS OF TAX DEDUCTED AND DEPOSITED INTO CENTRAL GOVERNMENT AC

    NAME OF THE BANK BRANCH WHERE TAX

    0 Sep-09 ----

    0 Oct-09 ----

    0 Nov-09 ----

    0 Dec-09 ----

    0 Jan-10 ----

    0 Feb-10 ----

    0 T.D.S. ON CAS & OTHER ARREARS

    0 TOTAL TAX DEDUCTED AT SOURCE

    Signature of the person responsible for deductionPlace : KHADKHAD Full name :Date : Designation :

    Note : See sections 15 and 17 and rule 3. Furnish separate details of value of perquisites and profitsin lieu of or in addition to salary or wages

    AMOUNT Rs. MONTH / DATE OFPAYMENT

    Certified that a sum of Rs. ( in words ) onlyhas been deducted at source and paid to the credit of Central Government. Further certified tinformation is true and correct as per records

    [email protected]

    mailto:[email protected]:[email protected]
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    ARIYA

    RELI

    6876Ment Year

    -2011

    DRs.

    184917

    184917

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    109536109540

    00

    0

    0

    00

    0

    0

    OUNT

    EPOSITED

    of tax

    hat the above

    om

    mailto:[email protected]:[email protected]
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    FORM

    ITR - 1

    INDIAN INCOME TAX RETURN Assessment Year

    [For Individuals having Income from Salary / Pension / Family Pension & Interest]

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

    PERSONALINFORMATION

    First name Middle name Last name PAN

    DIVYESH SHAMBHUBHAI ANSODARIYA AFSPA6876MFlat / Door / Block No. Name of Premises / Building / Village Date of Birth (DD/MM/YYYY)

    KHADKHAD 29.3.1979Road / Street / Post Office Area / Locality Employer Category (Tick) a

    Govt PSU Ot

    Town / City / District State Pin code Sex ( Tick) a

    AMRELI GUJARAT 3 6 5 4 8 0 Male Female

    Email address (STD code) - Phone number

    -

    FILINGSTATUS

    Return Filed Under Section -

    [Please see instruction number 9(i)]

    Whether original or Revised Return ? (Tick) a Original Revised

    / /

    Residential Status (Tick) a Resident Non-Resident Resident but Not Ordinarily Resident

    INCOME&DEDUC

    TIONS

    1 Income Chargeable under the Head 'Salaries' (Salary / Pension) 1 18492 Income Chargeable under the Head 'Other Sources' 2

    3 Gross Total Income (1+ 2c) 3 18494 Deduction under Chapter VI A (Section)

    a 80C 75381 e 80DD i 80GGb 80CCC f 80DDB j 80GGA

    c 80CCD g 80E k 80GGC

    d 80D 0 h 80G 0 l 80U 0m Deductions ( Total of a to l) 4m 753

    5 Total Income (3 - 4m) 5 10956 6

    7 'Aggregate Income' (5 + 6 ) 7 1095

    TAXCOMPU

    TATION

    8 a Tax Payable on 'Aggregate Income' 8a

    b Rebate in respect of Net Agricultural Income 8b

    9 a Tax Payable on Total Income (8a - 8b) 9a 0b Surcharge on 9a 9b 0c Education Cess on (9a + 9b) 9c 0d Total Tax, Surcharge and Educational Cess Payable (9a + 9b + 9c) 9d

    10 Relief under section 89 10 0

    11 Relief under section 90 / 91 11

    12 Balance Tax Payable (9d - 10 - 11) 12

    Do not write or stamp in this area (Space for bar code) For Office Use only Seal and signature of the receiving official

    Receipt No.

    Date

    Designation of the Assessing Officer(Ward / Circle)

    If revised enter Receipt No. and date of filing originalreturn (DD/MM/YYYY)

    Net Agricultural Income (Enter only if greater than Rs. 5,000)

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    13 a Interest Payable U/S 234 A 13a

    b Interest Payable U/S 234 B 13b

    c Interest Payable U/S 234 C 13c

    d Total Interest Payable (13a +13b + 13c) 13d

    14Total Tax and Interest Payable

    14(12 + 13d)

    TAX

    ESPAID

    15 Taxes Paid

    a 15a 0b 15b 0

    c 15c 0d Total Taxes Paid (15a + 15b + 15c) 15d16 16

    REFUND

    17 17

    18

    19 Do you want your refund by Cheque, or Deposited directly into your bank account? (tick as applicable) a

    20 In case of direct deposit in your bank account give additional details

    MICR CODE Type of account (tick as applicable) a Savings Current

    21 Details of Tax Deducted at Source from Salary [as per Form 16 issued by Employer(s)]

    TDSONSALAR

    YName and address of the Employer

    (1) (2) (3) (4) (5) (6) (7) (8)

    i HEAD MASTER184917 75381 0 0 0R K T T 0 0 6 8 9 D KHADKHAD PRIMARY SCHOOL

    ii

    22 Details of Tax Deducted at Source on Interest [as per Form 16A issued by Deductor(s)]

    TDSO

    NINTEREST

    Name and address of the Deductor Amount paid / credited Date of payment / credit

    (1) (2) (3) (4) (5) (6) (7)

    i

    ii

    iii

    Note Enter the total of column (7) of 21 and column (7) of 22 in Sl. No. 15b of TAXES PAID

    23 Details of Advance Tax and Self Assessment Tax Payments

    TAXPAYMENTS

    Name of Bank & Branch BSR Code Amount (Rs.)

    i

    ii

    iii

    iv

    v

    Note Enter the totals of Advance tax and Self Assessment tax in Sl. 15a and 15c of TAXES PAID

    24Sl code Amount (Rs) Sl code Amount (Rs) Sl code

    a 001 d 004 g 007

    b 002 e 005 h 008

    c 003 f 006

    25 25

    26 E-filing Acknowledgement Number Date (DD/MM/YYYY) / /

    VERIFICATION

    I. DAFDA KANTIBHAI KHODABHAI son / daughter of solemnly

    Place KHADKHAD Date Sign Here

    Advance Tax (from item 23)

    TDS (column 7 of item 21 + column 7 of item 22)

    Self Assessment Tax (from item 23)

    Tax Payable (14 - 15d) (Enter if 14 is greater than 15d , else leave blank)

    Refund (15d -14) (Enter if 15d is greater than 14, also give Bank Account details below)

    Enter your bank account number(mandatory in case of refund)

    SlNo.

    Tax deduction Account Number (TAN) ofthe Employer

    Incomechargeable

    under the head

    Deduction underChapter VI-A

    Tax payable (incl.surch. and edn.

    cess)

    Total taxdeposited

    Tax payable /refundable

    SlNo

    Tax deduction Account Number (TAN) ofthe Deductor

    Total taxdeposited

    Amount out of(6) claimed forthis year

    SlNo

    Date of Deposit(DD/MM/YYYY)

    Serial No. ofChallan

    Other Information (transactions reported Through Annual Information Return) (Please see instruction number -9(ii) for code)

    Tax - exempt interest income (for reporting purposes only)

    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 another 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 Incom

    tax for the previous year relevant to the Assessment Year 2009-10

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    28If TRP is entitled for any reimbursement from the Government, amount thereof(to be filled by TRP)

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    SARAL ITS-2D[*INCOME-TAX RETURN FORM FOR NON CORPORATE ASSESSEES OTHER THAN

    PERSONS CLAIMING EXEMPTION UNDER SECTION 11 ][ See proviso to rule 12( I )( b ) ( III )]

    1. NAME : DIVYESH SHAMBHUBHAI ANSODARIYA2. OFFICE NAME KHADKHAD PRIMARY SCHOOL3. ADDRESS : KHADKHAD Ta. VADIA Dist. AMRELI

    PIN : TELEPHONE :

    4. Permanent Account Number : AFSPA6876M 8. Ward/Circle/Special Range :5. Date of Birth 29.3.1979 9. SEX : Male / Female MALE6.

    INDIVIDUAL10. Income for the year i.e. 2009-201011. 2010-2011

    7. 12. Return Original or Revised : ORIGINAL13. Details of Bank Acconts :

    Name of the Bank Address of the Bank Account Number

    *Please tick[ ] the bank account,where you would like the amount of refund to be credited14. Details of Credit Card :

    15. INCOME FROM SALARY ( ATTACH FORM NO.16 ) 701 Rs. 184917.0016. INCOME FROM HOUSE PROPERTY 702 Rs.17. INCOME FROM BUSINESS OR PROFESSION 703 Rs.18. CAPITAL GAINS 15/9 15/12 15/3 31/3 TOTAL

    ( a ) Short term 645 646 647 648 704( b ) Long term 695 696 697 698 705 776 Rs.

    19. INCOME FROM OTHER SOURCES 706 Rs. 0.0020. INCOME OF ANY OTHER PERSON TO BE ADDED 775 Rs.21. GROSS TOTAL INCOME (15+16+17+18+19+20) 746 Rs. 184917.0022. LESS : DEDUCTION UNDER CHAPTER VI-A : SECTION Rs.

    Code (For Office Use) Section Amount(Rs.)( a ) 80 C 75381( b ) 80 D 0( c ) 81 U 0 747 Rs. 75381.00

    23. TOTAL INCOME : (21 - 22 ) 760 Rs. 109536.0024. ADD : AGRICULTRAL INCOME ( For rate purpose ) 762 Rs.25. INCOME CLAIMED TO BE EXEMPT FROM INCOME TAX 125 Rs.

    26. TAX ON TOTAL INCOME INCOME INCOME TAX( a )At normal rates 772 109540.00 802 0.00( b ) At special rates 768 801 810 Rs. 0.00

    27. LESS : REBATE 820 Rs.28. TAX PAYABLE 826 Rs. 0.0029. ADD SURCHARGE 828 Rs. 0.0030. TOTAL TAX PAYABLE (28+29) 832 Rs. 0.0031. LESS : RELIEF 837 Rs. 0.0032. NET TAX PAYABLE 840 Rs. 0.0033. LESS : TAX DEDUCTED AT SOURCE 840 Rs. 0.0034. LESS : ADVANCE TAX PAID 873 Rs.

    Date Date Date

    Amount Amount Amount 862 Rs.

    35. ADD : INTEREST PAYABLE U/s 234 234B 234C Total 851 Rs.36. LESS : SELF ASSESSMENT TAX PAID 875 Rs.37. BALANCE TAX : PAYABLE / REFUNDABLE 891 Rs. 0.00

    DOCUMENTS ATTACHED WITH THE RETURN1. Form No. 16 (Original) 2. TDS Certificate3. 4.

    VERIFICATIONI, DIVYESH SHAMBHUBHAI ANSODARIYA ( name in full and in block letters),

    son / daughter of solemniy declare that to the best of my knowledgeand belief, the information given in this return and the annexures and statements accompanying it are correct.,completeand truly stated and in accordance with the provisions of Income Tax Act. 1961, in respect of income chargeble toincome tax for the previous year relevant to the assessment year 2010-2011

    Receipt No. Date

    Signature

    Assessment YearResident :- INDIAN

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    Signature of the receiving official Place : AMARNAGAR

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    GOVERNMENT OF INDIAINCOM TAX DEPARTMENT

    ACKNOWLEDGEMENT

    Received with thanks form: DIVYESH SHAMBHUBHAI ANSODARIYA a return of income and/orreturn of fringe benefits in Form No ITR - 1 for assessment year 2010-2011,having the following particulars:

    RSONALINFORMATI Name PAN NO.

    DIVYESH SHAMBHUBHAI ANSODARIYA AFSPA6876MFlat/Door/Block No: Name of Premises/Building/Village:

    KHADKHADRoad/Street/Post Office: Area/Locality:

    Town/City/District: State:AMRELI GUJARAT

    1 Gross total income 1 1849172 Deduction under Chapter-VI-A 2 753813 Total Income 3 1095364 Net tax payable 4 05 Interest payable 5 06 Total tax and interest payable 6 07 Taxes paid

    a Advance Tax 7a 0b TDS 7b 0c TCS 7c 0d Self Assessment Tax 7d 0e Total Taxes paid (7a+7b+7c+7d) 7e 0

    8 Tax payable (6-7e) 8 09 Refund (7e-6) 9 0

    10 Value of Fringe Benefits 10 011 Total fringe benefit tax liability 11 012 Total interest payable 12 013 Total tax and interest payable 13 014 Taxes paid

    a Advance Tax 14a 0b Self Assessment Tax 14b 0c Total Taxes paid (14a+14b) 14c 0

    15 Tax payable (13-14c) 15 016 Refund (14c-13) 16 0

    Receipt No. Seal and Signature of receiving official:

    Date:

    COMPUTATIO

    N

    OFINCOME&TAXTHEREON

    Compu

    tationo

    fIncome

    &

    Fringe

    Benefi

    ts&Tax

    Thereon

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