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First Name Middle Name Last Name PAN

DHARMENDRA MIHILAL SINGH BCOPS6669A


Flat / Door / Building Status
Vill- Kachpura I
INFORMATION

Road/Street/Post Office Area/Locality DOB (YYYY/MM/DD)


PERSONAL

Post- Nawabganj 1980-03-01


Town/City/District State Pin code Sex
Distt- Farrukhabad UTTAR PRADESH 209625 M
Country
91- INDIA Employer Category
Email id (STDcode)-Ph No Mobile No.
[email protected] ( )- 8447998246 OTH
,
Income Tax Ward/Circle Return filed under Section- 17
[Please see instruction number-9(ii)]
Whether Original or Revised return? R
FILING STATUS

If revised, enter Original Ack no / 698023710290713 Date 2013-07-29


Date
If u/s 139(9)-defective return , enter
Original Ack No
If u/s 139(9)-defective return , enter If u/s 139(9)-defective return , enter
Notice No Notice Date
Residential Status RES Tax Status TR
Whether Person governed by N
Portuguese Civil Code under Sec 5A ?
1 Income from Salary / Pension (Ensure to fill Sch TDS1) 1 401836
Type of House Property
2 Income from one House Property 0
3 Income from Other Sources (Ensure to fill Sch TDS2) 0
4 Gross Total Income (1+2+3) 4 401836
5 Deductions under chapter VI A (Section)
a 80C 89932 89932 h 80G 0 0
b 80CCC 0 0i 80GG 0 0
c 80 CCD 0 0 j 80GGA 0 0
INCOME & DEDUCTIONS

(i) (Employers
Contribution)
c 80 CCD 0 0 k 80GGC 0 0
(ii) (Employees /
Self Employed
Contribution)
d 80D 0 0l 80U 0 0
e 80DD 0 0 m 80CCG 0 0
f 80DDB 0 0 n 80RRB 0 0
g 80E 0 0 o 80QQB 0 0
p 80TTA 0 0
6 Deductions (Total of 5a to 5p) 6 89932
7 Total Income (4-6) 7 311900
8 Tax Payable on Total Income 8 11190
9 Education Cess, including secondary and higher secondary cess on 8 9 336
COMPUTATION

10 Total Tax and Education Cess (Payable)(8+9) 10 11526


11 Relief under Section 89 11 0
12 Balance Tax Payable (10-11) 12 11526
TAX

13(i) Interest u/s 234A 0


13(ii) Interest u/s 234B 0
13(iii) Interest u/s 234C 0
14 Total Interest u/s 234A 234B 234C 14 0
15 Total Tax and Interest Payable (12+14) 15 11526
16 Taxes Paid
TAXES PAID a Advance Tax (from item 25) 16a 0
b TDS (Total from item 23 + item 24) 16b 12250
c Self Assessment Tax (item 25) 16c 0
Total Taxes Paid(16a + 16b + 16c) 17 12250
17
18 Tax Payable (15-17) (if 15 is greater than 17) 18 0
19 Refund (17-15) if 17 is greater than 15 19 720
20 Enter your Bank Account Number 00891140042279
REFUND

21 Select Yes if you want your refund by direct deposit into bank account, select No if you want refund by cheque
Y
22 In case of direct deposit to your bank account give additional details
IFSC Code Type of Account SAV
HDFC0000089
23 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]
SI.NO Tax Deduction Name of the Employer Income chargeable Total Tax Deducted
Account Number under the
(TAN) of the head Salaries
Employer
1 DELA03276A ALCHEM INTERNATIONAL LIMITED 275361 12250
26 Exempt income for reporting purposes only
VERIFICATION
xyz
I, DHARMENDRA MIHILAL SINGH son/daughter of MIHILAL LALTAPRASAD SINGH 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 2013-14.

Place DELHI Date 2013-08-08 PAN BCOPS6669A

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
28 If TRP is entitled for any reimbursement from the Government, amount thereof

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