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1 1

2 2

3 3

4 4

5

O-Original

Nil Tax Balance

If u/s 139(9)-

defective return ,

enter Notice Date

Assessment

Year

2 0 1 2 - 1 3

If revised, enter Original Ack no / Date

Town/City/District

00/00/0000

Whether original or revised return?

Tax StatusRES - Resident

If u/s 139(9)-defective return , enter

Original Ack No

Date

If u/s 139(9)-defective return , enter Notice

No

Residential Status

System Calculated

Income from Other Sources (Ensure to fill Sch TDS2)

Gross Total Income (1+2+3)

Deductions under Chapter VI A (Section)

0

0

0

0

0

b 0

[Pl see Form Instruction]

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

11-BeforeDueDt

Area / Locallity

OTH

Flat / Door / Building

(Std code)Email Address

[For Individuals having Income from Salary / Pension / Income from One House Property (excluding

loss brought forward from previous years) /

Income from Other Sources (Excluding Winning from Lottery and Income from Race Horses)]

INDIAN INCOME TAX RETURN

Income Tax Ward / Circle Return filed under section

Sex (Select)

Road / Street

0

c(i)

a 80 C

Income from one House Property

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

Mobile no

State

Last Name PAN

Status

I - Individual

PER

SONALINFORMATION

ITR-1

FORM

SAHAJ

First Name Middle Name

Date of birth (DD/MM/YYYY)

employment)

Pin Code

Phone No

M-Male

Employer Category (if in

FILINGSTATUS

80 CCC

80 CCD (Employers Contribution)

5b

5c(i)

&DEDUCTIONS

0

5a

80 CCF 0

0

0

c(ii)80 CCD (Employees / Self Employed

Contribution)5c(ii)

0

d 5d

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23

SI.No

Tax Deduction

Account Number

(TAN) of the

Employer

Name of the

Employer

Income charg

eable under the

head Salaries

Total tax

Deducted

(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

SI.No

Tax Deduction

Account Number

(TAN) of the

Deductor

Name of the

Deductor

Unique TDS

Certificate No.

Deducted

Year

Total tax

Deducted

Amount

out of

(6)

claimed

forthis ear

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

1

2

3

4

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

25

BSR Code

Date of Credit into

Govt Account

(DD/MM/YYYY)

Serial

Number of

Challan

Amount (Rs)

1

2

3

4

5

6

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

Details of Tax Deducted at Source on Income OTHER THAN SALARY

[As per FORM 16 A issued by Deductor(s)]

Details of Tax Deducted at Source from SALARY

[As per FORM 16 issued by Employer(s)]

Sl No

Details of Advance Tax and Self Assessment Tax Payments

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16

a 16a 0

b 16b0

c 16c 017 Total Taxes Paid (16a+16b+16c) 17 0

18 18 0

19 19 0

20

21 No

22

26 Exempt income for reporting purposes only

son/daughter of

27 If the return has been prepared by a Tax Return Preparer (TRP) give further details as below:

28

TAXESPAID

VERIFICATION

Advance Tax (from item 25)

Date

Name of TRP

Tax Payable (15-17) (if 15 is greater than 17)

Self Assessment Tax (item 25)

Taxes Paid PLEASE NOTE THAT CALCULATED FI ELDS (IN WHI TE) ARE PICKED UP

FROM OTHER SCHEDULES AND ARE NOT TO BE ENTERED. For ex : The taxes paid figur es

below wil l get fi ll ed up when the Schedules linked to them ar e fil led.

REFUND

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 2012-13

Sign here ->Place

PAN

I,

TDS (Total from item 23 + item 24)

Refund (17-15) if 17 is greater than 15

Type of Account(As applicable)

In case of direct deposit to your bank account give additional details

Enter your Bank Account number

MICR Code

Identification No of TRP

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

filled by TRP)

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Schedule 80G Details of donations entitled for deduction under section 80G (PLEASE READ NOTE BELOW)

A

Name of

donee

Adress City or Town or

District

State Code PinCode PAN of Donee Amount of

donation

Eligible

Amount of

Donation

1 02 0

3 0

4 0

0 0

B Donations entitled for 50% deduction without qualifying limitName of

donee

Address City or Town or

District

State Code PinCode PAN of Donee Amount of

donation

Eligible

Amount of

Donation1 0

2 0

3 0

4 0

0 0

C Donations entitled for 100% deduction subject to qualifying limit

Name of

donee

Address City Or Town Or

District

State Code PinCode PAN of Donee Amount of

donation

Eligible

Amount of

Donation1 0

2 0

3 0

4 0

0 0

Total 80GA

Total 80GB :

Total 80GC :

Donations entitled for 100% deduction without qualifying limit

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D Donations entitled for 50% deduction subject to qualifying limit

Name of

donee

Address City Or Town Or

District

State Code PinCode PAN of Donee Amount of

donation

Eligible

Amount of

Donation1 0

2 0

3 0

4 0

0 0

E Donations (A + B + C + D) 0 0

NOTE : (IN CASE OF DONEE FUNDS SETUP BY GOVERNMENT AS DESCRIBED IN SECTION 80G(2),

PLEASE USE PAN AS "GGGGG0000G".

Total 80GD