FORM NO 4A
[See chapter XII-C of the Income-tax Act, 1961 and rule 11EE of the Income-tax Rules]
Statement under the simplified procedure
HEAD: 0021 INCOME-TAX – SIMPLIFIED PROCEDURE
|
1. NAME (SURNAME FIRST) (IN BLOCK LETTERS) |
|||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||
|
2. |
FINANCIAL YEAR [ |
1 |
9 |
9 |
6 |
—- |
1 |
9 |
9 |
7 |
] |
||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||||||
|
3. |
RESIDENTIAL ADDRESS |
||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
4. |
BUSINESS ADDRESS (IN BLOCK LETTERS) |
||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
5. |
STATUS* |
INDIVIDUAL |
|
|
HINDU UNDIVIDED FAMILY |
|
|
|
|
||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||||||
|
6. |
NATURE OF BUSINESS OR VOCATION* |
||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||
|
RETAIL TRADE |
|
|
EATING PLACE |
|
|
TAILORING |
|
|
HAIR CUTTING |
|
|
|
|||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||
|
TYPING |
|
|
PHOTOCOPYING |
|
|
REPAIR WORK |
|
|
WASHING CLOTHS |
|
|
|
|||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
OPERATING/HIRING/LEASING TRANSPORT VEHICLE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
ANY OTHER VOCATION – SPECIFY |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
7. |
DEEMED INCOME FROM BUSINESS OR VACATION : |
|
|
|
|
|
|
[ |
Rs. |
4 |
9 |
3 |
3 |
0 |
] |
||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
8. |
INCOME FROM SOURCES OTHER THAN BUSINESS OR |
|
|
|
|
|
|
Rs. |
|
|
|
|
|||||||||||||||||||||||||
|
|
VOCATION CHARGEABLE TO TAX [NOT EXCEEDING Rs. 5,0000 |
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
9. |
DIDUCTION UNDER SECTION 80L in respect of income from dividend , |
|
|
|
|
Rs. |
|
|
|
|
|||||||||||||||||||||||||||
|
|
Interest on bank deposits and on other specified deposits and such securities |
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||
|
|
[NOT EXCEEDING Rs. 5,000] |
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
10. |
NET INCOME FROM SOURCES OTHER THAN BUSINESS OR |
|
|
|
|
Rs. |
|
|
|
|
|||||||||||||||||||||||||||
|
|
VOCATION [8 MINUS 9] |
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||
|
11. |
TAX PAYABLE [Rs. 1,400 plus 20% OF AMOUNT AT (10)] |
|
|
|
|
Rs. |
|
|
|
|
|||||||||||||||||||||||||||
Vrification
[I, …………….(name in full and block letters) **son/daughter/wife/karta/member of Hindu undivided family hereby declare that what is stated is true to the best of my knowledge and belief.
I further declare that I have not been assessed to income-tax for any assessment year commencing on or before 1st April, 1992.
I also hereby declare that my income during the financial year 1996-97 from the business or vocation mentioned at item 6 does not exceed forty-nine thousand three hundred and thirty rupees and I do not have any income exceeding Rs. 5,000 from sources other than business or vocation mentioned above.
Date …………………… …………………………………………………
Place ………………….. (Name and signature)
Note:
*Tick the one which is applicable.
**Strike out whichever is not applicable.
|
Paid in cash/by cheque/draft No ……….. dated……….. Rupee ………………………….. Rs. …………………………… [in words] [in figures] into …………………………….. Branch of …………………… [Name of the bank]
………………………………………………………………………… Signature of the person making the payment |
FOR USE INTHE RECEIVING BANK |
|
RECEIVED PAYMENT
Serial No. In Scroll Cheque/draft tendered on Cheque/draft realised on
Signature of chashier |
|
|
|
STAMP OF THE BANK] |
