Government of Pakistan

Department of Income Tax

Office of the ____________

The Commissioner

__________ _______________________________________

_________________________________________________ (City)

Dear Sir,

I, ____________________________________________________________________ of

_______________________________________________________________________ hereby declare

a. That my total income computed in accordance with the provisions of Income Tax Ordinance,

2001 (XLIV of 2001), during the year ending on ______________ being the income year for

the assessment for the year ending on the ________________ amounted to Rs.

_______________.

b. That the total tax chargeable in respect of such total income is Rs. ______________.

c. That the total amount of tax paid is Rs. ______________.

I, therefore, request that a refund of Rs. ________________ may be allowed to me.

Yours faithfully ______________________

Signature __________________________

NTN ______________________________

Address ___________________________

I hereby declare that I am resident/ non-resident* and that what is in this application is correct.

Date ___________________ Signature _________________

* Delete whichever is in applicable.