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SAHAJ INDIAN INCOME TAX RETURN Assessment Year

[For Individuals having Income from Salary / Pension / Income from One House Property Year
FORM ITR-1 (excluding loss brought forward from previous years) /
Income from Other Sources (Excluding Winning from Lottery and Income from Race Horses)]

(Please see rule 12 of the Income-tax Rules,1962) (Also see attached instructions) 2011-12
First Name Middle Name Last Name PAN
PERSONAL INFORMATION

Flat / Door / Building Status


I - 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)
STATUS
FILING

Whether original or revised return? O-Original


If revised, enter Receipt no / Date Date
Residential Status RES - Resident
1 Income from Salary / Pension (Ensure to fill Sch TDS1) 1
Income from one House Property
2 2

Income from Other Sources (Ensure to fill Sch TDS2)


3 3
4 Gross Total Income (1+2c) 4 0
INCOME & DEDUCTIONS

5 Deductions under Chapter VI A (Section) System Calculated


a 80 C 5a 0
b 80 CCC 5b 0
c 80 CCD 5c 0
d 80 CCF 5d 0
e 80 D 5e 0 0
f 80 DD 5f 0
g 80 DDB 5g 0
h 80 E 5h 0
i 80 G 5i 0 0
j 80 GG 5j 0 0
k 80 GGA 5k 0
l 80 GGC 5l 0
m 80 U 5m 0
6 Deductions (Total of 5a to 5m) 6 0 6 0
7 Total Income (4 - 6) 7 0
TAX COMPUTATION

8 Tax payable on Total Income 8 0


9 Education Cess, including secondary and higher secondary cess on 8 9 0
10 Total Tax, Surcharge and Education Cess (Payable) (8 + 9) 10 0
11 Relief under Section 89 11 0
12 Relief under Section 90/91 12 0
13 Balance Tax Payable (10 - 11 - 12) 13 0
14 Total Interest Payable 14 0
15 Total Tax and Interest Payable (13 + 14) 15 0
For Office Use Only Seal and Signature of
Receipt No/ Date Receiving Official
23 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]
Tax Deduction
Income charg
Account Number Name of the Total tax
SI.No eable under the
(TAN) of the Employer Deducted
head Salaries
Employer
(1) (2) (3) (4) (5)
1
2
3
(Click + to add more rows to 23) TDS on Salary above. Do not delete blank rows. )
24 Details of Tax Deducted at Source Other than Salary
Amount out
Tax Deduction
of
Account Number Name of the Total tax
SI.No (6) claimed
(TAN) of the Deductor Deducted
for
Deductor
this year
(1) (2) (3) (4) (5)
1
2
3
4
(Click + to add more rows ) TDS other than Salary above. Do not delete blank rows. )

25 Details of Advance Tax and Self Assessment Tax Payments

Sl No Serial
Date of Deposit
BSR Code Number of Amount (Rs)
(DD/MM/YYYY)
Challan
1
2
3
4
5
6

(Click '+' to add more rows ) Tax Payments. Do not delete blank rows. )
16 Taxes Paid
0

TAXES PAID
a Advance Tax (from item 25) 16a
b TDS (column 7 of item 23 +column 7 16b
0
of item 24)
c Self Assessment Tax (item 25) 16c 0
17 Total Taxes Paid (16a+16b+16c) 17 0
18 Tax Payable (15-17) (if 15 is greater than 17) 18 0
19 Refund (17-15) if 17 is greater than 15 19 0
20 Enter your Bank Account number (Mandatory )
REFUND

21 Select Yes if you want your refund by direct deposit into your bank account, No
Select No if you want refund by Cheque
22 In case of direct deposit to your bank account give additional details
MICR 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
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
Place Date Sign here ->

PAN
27 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
28
filled by TRP)

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