FOR INDIVIDUAL & OTHER TAXPAYERS (OTHER THAN COMPANY)

FORM OF RETURN OF INCOME UNDER THE INCOME TAX IT-11GA

ORDINANCE, 1984 (XXXVI OF 1984)

Be a Respectable Taxpayer Photograph of the

Submit return in due time Assessee
Avoid penalty
[to be attested on
the photograph]
Put the tick () mark wherever applicable
Self Universal Self Normal

1. Name of the Assessee:

2. National ID No (if any) :

3. UTIN (if any): -

4. TIN:

5. (a) Circle: 06 .. (b) Taxes Zone: DHAKA - 03

6. Assessment Year: .2011-2012. 7. Residential Status: Resident /Non-resident 

8. Status: Individual  Firm  Association of Persons  Hindu Undivided Family 

9. Name of the employer/business (where applicable): ..................................................................

10.Husband's Name (if assessee, please mention TIN):

11. Father's Name:

12. Mother’s Name:

13. Date of Birth (in case of individual) : 0 1 1 2 1 9 7 6

Day Month Year

14. Address (a) Present:

........................................................................................................

(b) Permanent:

15. Telephone: Office/Business 9560064,9550514 Residential: .01944749010

16. VAT Registration Number (if any): ..........................................................................................

Statement of income of the Assessee

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 Statement of income during the income year ended on .30-06-2011.
Heads of Income Amount in taka
1. Salaries : u/s 21 (as per schedule 1) 6,42,639.00
2. Interest on Securities : u/s 22
3. Income from house property : u/s 24 (as per schedule 2)
4. Agricultural income : u/s 26
5. Income from business or profession : u/s 28
6. Share of profit in a firm :
7. Income of the spouse or minor child as applicable : u/s 43(4)
8. Capital Gains : u/s 31
9. Income from other source : u/s 33
10. Total (Serial 1 to 9) 6,42,639.00
11. Foreign Income:
12. Total income (Serial 10 and 11) 6,42,639.00
13. Tax leviable on total income (30,000.00 of 10% + 21,395.85 of 15 %) 51,395.85
14. Tax rebate: u/s 44(2)(b)(as per schedule-3) (20% of 6,42,639.00) 12,852.00
15. Tax payable (difference between serial 13 and 14) 38543.85
16. Tax Payments:
(a) Tax deducted/collected at source
(Please submit supporting documents/statement) Tk 43,875.00
(b) Advance tax u/s 64/68 (Please attach challan ) Tk ..............

(c) Tax paid on the basis of this return (u/s 74)

(Please attach challan/pay order/bank draft/cheque) Tk ..............
Tk. 43,875.00
(d) Adjustment of Tax Refund (if any) Tk ..............

Total of (a) (b), (c) and (d)

17. Difference between serial 15 and 16 (if any) -5,331.15
18. Tax exempted & Tax free income Tk. 2,59,060.00
19. Income tax paid in the last assessment year Tk. 14,700.00

*If needed, please use separate sheet.

Verification
I am ………….. husband . ………… UTIN/TIN: 076-113-4054 solemnly declare
that to the best of my knowledge and belief the information given in this return and statements and
documents annexed herewith is correct and complete.

Place: .Dhaka-03
Date : .28-09-2011 Signature

(lllllll)
Dy. Manager
Seal (for other than individual)

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 SCHEDULES SHOWING DETAILS OF INCOME

Name of the Assessee: Shamsun Naher TIN 0 7 6 - 1 1 3 - 4 0 5 4

Schedule-1 (Salaries)
Pay & Allowance Amount of Amount of Net taxable
Income exempted income
(Tk.) income (Tk.) (Tk.)
Basic pay 5,13,283.00 5,13,283.00
Special pay 33,000.00 33,000.00
Dearness allowance
Conveyance allowance 24,500.00 24,000.00 500.00
House rent allowance 1,78,251.00 1,78,251.00
Medical allowance
Servant allowance
Leave allowance
Honorarium / Reward/ Fee
Overtime allowance
Bonus / Ex-gratia 94,056.00 94,056.00
Other allowances 1,800.00 1,800.00
Employee’s Contribution to Recognized 56,809.00 56,809.00
Provident Fund
Interest accrued on Recognized Provident Fund
Deemed income for transport facility
Deemed income for free furnished/unfurnished
accommodation
Other, if any (give detail)
Net taxable income from salary 9,01,699.00 2,59,060.00 6,42,639.00
Schedule-2 (House Property income)
Location and Particulars Tk. Tk.
description of
property
1. Annual rental income
2. Claimed Expenses :
Repair, Collection, etc.
Municipal or local tax
Land Revenue
Interest on loan/Mortgage/Capital
charge
Insurance Premium
Vacancy allowance
Other, if any
Total =
3. Net income ( difference between serial 1 and 2)

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 Schedule-3 (Investment tax credit)
(Section 44(2)(b) read with part ‘B’ of Sixth Schedule)
1. Life insurance premium Tk ........................................
2. Contribution to deferred annuity Tk 1,13,618.00
3. contribution to Provident Fund to which Provident Fund Tk ........................................
Act,1925 applies
4. Self contribution & employer’s contribution to Tk ........................................
Recognized Provident Fund
5. Contribution to Super annuation Fund Tk ........................................
6. Investment in approved debenture or debenture stock, Tk ........................................
Stock or Shares
7. Contribution to deposit pension scheme Tk ........................................
8. Contribution to Benevolent Fund and group insurance premium Tk ........................................
9. Contribution to Zakat Fund Tk ........................................
10. Others, if any ( give details ) Tk . 50,000.00
Total Tk 1,63,618.00

*Please attach certificates of investment.

List of documents furnished

1. Certification of Collection Text 6. Land Purchase Document

2. Salary Statement 7.

3. Tex Pay Statement 8.

4.50,000.00 (Saving Certification) Sale 9.

Document

5. Bank Statement 10.

Incomplete return is not acceptable

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 IT-10B
Statement of assets and liabilities (as on 30-06-2011.)

Name of the Assessee: Shamsun Naher TIN 0 7 6 - 1 1 3 - 4 0 5 4

1. (a) Business Capital (Closing balance) Tk. ..........................

(b) Directors Shareholdings in Limited Companies ( at cost) Tk. ..........................
Name of Companies Number of shares

2. Non-Agricultural Property (at cost with legal expenses ) : Tk. 6,75,000.00

Land/House property (Description & location of property)
(JL-220,SA-99, RS-25, Mouza- Senpara Parbata Land- 0.33 Khata/0.55 Decimal)
Attested Document

3. Agricultural Property (at cost with legal expenses ) : Tk. .........................

Land (Total land and location of land property)

4. Investments:
(a) Shares/Debentures Tk. .......................
(b) Saving Certificate/Unit Certificate/Bond Tk. .. 50,000.00
(c) Prize bond/Savings Scheme Tk. .............................
(d) Loans given Tk. .............................
(e) Other Investment Tk. .............................
Total = Tk. . 50,000.00

5. Motor Vehicles (at cost) : Tk. ..........................

Type of motor vehicle and Registration number

6. Jewellery (quantity and cost) : (LAST YEAR) Tk. .3,00,000.00

7. Furniture (at cost) : (LAST YEAR) Tk. ..1,50,000.00

8. Electronic Equipment (at cost) : Tk. 3,00,000.00

9. Cash asset Outside Business:

(a) Cash in hand Tk. .11,59,346.60
(b) Cash at bank Tk. 52476.00
(c) Other deposits Tk. .............................
Total = Tk 26,86,822.60

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 B/F = Tk. 26,86,822.60

10. Any other assets Tk. ..........................

(Give details)

Total assets Tk. 26,86,822.60

11. Less Liabilities:
(a) Mortgages secured on property or land Tk. .............................
(b) Unsecured loans Tk. .............................
(c) Bank loan Tk. .............................
(d) Others Tk. .............................

Total liabilities Tk. ..........................

12. Net wealth as on last date of this income year

(difference between total assets & total liabilities) Tk. 26,86,822.60

13. Net wealth as on last date of previous income year Tk. 18,96,823.00
14. Accretion in wealth (difference between serial no. 12 & 13) Tk. 7,89,999.60

15. (a) Family Expenditure : (Total expenditure as per Form IT 10 BB) Tk. 1,11,700.00

(b) Number of dependant children of the family:

1 2
Adult Child

16. Total accretion of wealth (total of serial 14 & 15) Tk. 9,01,699.00
17. Sources of Fund :
(i) Shown Return Income Tk. 6,42,639.00
(ii) Tax exempted/Tax free Income Tk. 2,59,060.00
(iii) Other receipts Tk. …………………
Total source of Fund = Tk. 9,01,699.00

18. Difference (between serial 16 & 17) Tk. 0.00

I solemnly declare that to the best of my knowledge and belief the information given in the IT-10B is
correct and complete.

(Shamsun Naher)
Name & signature of the Assessee
Date 28-09-2011

 Assets and liabilities of self, spouse (if she/he is not an assessee), minor children and
dependant(s) to be shown in the above statements.
 If needed, please use separate sheet.

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 FORM Form No. IT-10BB

Statement under section 75(2)(d)(i) and section 80 of the Income Tax Ordinance,
1984 (XXXVI of 1984) regarding particulars of life style

Name of the Assessee: Shamsun Naher TIN 0 7 6 - 1 1 3 - 4 0 5 4

Serial Particulars of Expenditure Amount of Tk. Comments

No.
1. Personal and fooding expenses Tk. 15,000.00
2. Tax paid including deduction at source of the last Tk. 14,700.00
financial year
3. Accommodation expenses Tk. 30,000.00
4. Transport expenses Tk. 20,000.00
5. Electric Bill for residence Tk.
6. Wasa Bill for residence Tk.
7. Gas Bill for residence Tk.
8. Telephone Bill for residence Tk. 2,000.00
9. Education expenses for children Tk. 10,000.00
10. Personal expenses for Foreign travel Tk.
11. Festival and other special expenses, if any Tk. 20,0000.00
Total Expenditure Tk. 1,11,700.00 Shear by spouse

I solemnly declare that to the best of my knowledge and belief the information given in the
IT-10BB is correct and complete.

(Shamsun Naher)
Name & signature of the Assessee
Date 28-09-2011
If needed, please use separate sheet.

 ..................................................................................................................................................................
Acknowledgement Receipt of Income Tax Return

Name of the Assessee: . Assessment Year: ...2011-2012

UTIN/
0 7 6 1 1 3 - 4 0 5 4 Circle: 06 Taxes Zone .Dhaka 03
TIN:

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 Instructions to fill up the Return Form
Instructions:
(1) This return of income shall be signed and verified by the individual assessee or person as
prescribed u/s 75 of the Income Tax Ordinance, 1984.
(2) Enclose where applicable:
(a) Salary statement for salary Income; Bank statement for interest; Certificate for interest
on savings instruments; Rent agreement, receipts of municipal tax & land revenue,
statement of house property loan interest, insurance premium for house property
income; Statement of Professional income as per IT Rule-8; Copy of assessment/
income statement & balance sheet for partnership income; Documents of capital gain;
Dividend warrant for dividend income; Statement of other income; Documents in
support of investments in savings certificates, LIP, DPS, Zakat, stock/share etc.
(b) Statement of income and expenditure; Manufacturing A/C, Trading & Profit & Loss
A/C and Balance sheet;
(c) Depreciation chart claiming depreciation as per THIRD SCHEDULE of the Income
Tax Ordinance, 1984;
(d) Computation of income according to Income tax Law;
(3) Enclose separate statement for:
(a) any income of the spouse of the assessee (if she/he is not an assessee), minor children
and dependant;
(b) tax exempted / tax free income.
(4) Fulfillment of the conditions laid down in rule-38 is mandatory for submission of a return
under "Self Assessment".
(5) Documents furnished to support the declaration should be signed by the assessee or his/her
authorized representative.
(6) The assesse shall submit his/her photograph with return after every five year.
(7) Furnish the following information:
(a) Name, address & TIN of the partners if the assessee is a firm;
(b) Name of firm, address & TIN if the assessee is a partner;
(c) Name of the company, address & TIN if the assessee is a director.

(8) Assets and liabilities of self, spouse (if she/he is not an assessee), minor children and
dependant(s) to be shown in the IT-10B.
(9) Signature is mandatory for all the assessee or his/her authorized representative. For
individual, signature is also mandatory in I.T-10B & I.T-10BB.
(10) If needed, please use separate sheet.

 ..................................................................................................................................................................

Total income shown in Return: Tk 9,01,699.00 Tax paid: Tk ..43,875.00.

Net Wealth of Assessee : Tk 26,86,822.60
Date of receipt of return : ............................................. Serial No. in return register .......................

Nature of Return : Self Universal Self Normal

Signature of Receiving
officer with seal