FORM SARAL - II INDIAN INCOME TAX RETURN Assessment Year

[For Individuals having Income from Salary / Pension / Family Pension / Income
(ITR - 1) from One House Property (excluding loss brought forward from previous
years) / Income from Other Sources (Excluding winning from Lottery and 2 0 1 0 - 1 1
Income from Race Horses)]
(Please see Rule 12 of the Income-tax Rules, 1962) (Also see attached instructions)

-
First name Middle name Last name PAN
PERSONAL INFORMATION

KAVITA DEVI - AGTPR3155Q

Flat / Door / Block No. Name of Premises / Building / Village Date of Birth (DD/MM/YYYY)
- - 22-12-2008
Road / Street / Post Office Area / Locality Employer Category (Tick)

SUNARON KA BAS - a GOVT. PSU OTHER

Town / City / District State Pin code Sex ( Tick)

Senior Citizon NO
BARMER RAJASTHAN 3 4 4 0 0 1 MALE a FEMALE
Email address VKBOTHRA@YAHOO.COM STD CODE + Telephone
Designation of the Assessing Officer (Ward / Circle) Return Filed Under Section -
FILING STATUS

[Please see instruction number 9(i)]

11
ITO - BARMER
Whether original or Revised Return? a Original Revised
(Tick)
If revised enter Receipt No. and
date of filing original return
(DD/MM/YYYY) Resident but Not Ordinarily
Residential Status (Tick) a Resident Non-Resident
Resident
1 Income Chargeable under the Head 'Salaries' (Salary / Pension) 1 202,551.00
2 Income Chargeable under the Head 'House Property'(enter -ve sien in case of loss, 2 16,000.00
if any)
INCOME & DEDUCTIONS

3 Income Chargeable under the Head 'Other Sources' (enter -ve sien in case of loss, if 3 -
any)
4 Gross Total Income (1+ 2+3) 4 218,551.00
5 Deduction under Chapter VI A (Section)
a 80C ### e 80DD - i 80GG -
b 80CCC - f 80DDB - j 80GGA -
c 80CCD - g 80E - k 80GGC -
d 80D - h 80G - l 80U -
6 Deductions (Total of 5a to 5I) 6 38,953.00
7 Total Income (4 - 6) 7 179,598.00
8 Tax Payable on Total Income 8 -
TAX COMPUTATION

9 Secondary and Higher Eduction cess on 8 9 -

10 Total Tax and Education Cess Payable (8 + 9) 10 -
11 Relief under section 89 11 -
12 Relief under section 90 / 91 12 -
13 Balance Tax Payable (10-11-12) 13 -
14 Total Interest Payable u/s 234A / 234B / 234C 14 -
15 Total Tax and Interest Payable (12 + 13) 15 -
Do not write or stamp in this area For Office Use only Seal and signature of the receiving official

Receipt No.

Date
 16 Taxes Paid
TAXES PAID
a Advance Tax (from item 25) 16a -
b TDS (column 7 of item 23 + column 7 of item 25) 16b 8,000.00
c Self Assessment Tax (from item 25) 16c -
17 Total Taxes paid (16a+16b+16c) 17 8,000.00
18 Tax Payable (15-17) (Enter if 15 is greater than 17 , else leave blank) 18 -
19 Refund (17-16) (Enter if 15d is greater than 14, also give Bank Account details below) 19 8,000.00
20 Enter your bank account number (mandatory in case of refund) -
REFUND

21 Do you want your refund by a Cheque, or Deposited directly into your bank account? (tick as applicable)
22 In case of direct deposit in your bank account give additional details
MICR CODE Type of account (tick as applicable) a Savings Current

23 Details of Tax Deducted at Source from Salary [as per Form 16 issued by Employer(s)]
Sl Tax deduction Account Number Name and address of the Income Deducti Tax Total tax Tax
No. (TAN) of the Employer Employer chargeabl on payable deposited payable /
TDS ON SALARY

e under under (incl. refundabl

the head Chapter surch. e
Salaries VI-A and edn.
(1) (2) (3) (4) (5) (6)
cess) (7) (8)
i
202,551 38,953 - 8,000 8,000

ii

24 Details of Tax Deducted at Source on Interest [as per Form 16A issued by Deductor(s)]
Sl Tax deduction Account Number Name and address of the Amount paid / Date of Total tax Amount
No (TAN) of the Deductor Deductor credited payment/ deposited out of (6)
credit claimed
for this
year
(1) (2) (3) (4) (5) (6) (7)
i
TDS ON INTEREST

- -

ii
- -

iii
- -

iv
- -

v
- -

vi
- -
Note Enter the total of column (7) of 21 and column (7) of 22 in Sl. No. 15b of TAXES PAID
25 Details of Advance Tax and Self Assessment Tax Payments
Sl Name of Bank & Branch BSR Code Date of Deposit Serial No. of Amount (Rs.)
No (DD/MM/YYYY) Challan
TAX PAYMENTS

i 15/09 -
ADVANC

ii 15/12 -
E

iii 15/03 -
iv -
SELF

v -
Note Enter the totals of Advance tax and Self Assessment tax in Sl. 15a and 15c of TAXES PAID

26 Other Information (transactions reported Through Annual Information Return) (Please see instruction number -9(ii) for code)
Sl code Amount (Rs) Sl code Amount (Rs) Sl code
a 001 d 004 g 007
b 002 e 005 h 008
c 003 f 006

27 Exepmt income only for reporting purposes (from Dividend, Capital gains etc) 27

VERIFICATION
I KAVITA DEVI - daughter of BABULAL solemnly declare that to the
best of my knowledge and belief, the information given in this return thereto is correct and complete and that the amount of total income
and other particulars shown therein are truly stated and 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 2010-11.

Place BARMER Date 3-Feb-2011 Sign Here

28 If the return of Income has been prepared by a Tax Return Preparer (TRP) give further details as below:
Identification No. of TRP Name of TRP Counter sign by TRP

If TRP is entitled for any reimbursement from the Government, amount thereof (to be filled by TRP) 28
 INCOME TAX RETURN VERIFICATION FORM Assessment Year
IT INDIAN [Where the data of the Return of Income in Form SARAL-II (ITR-1), ITR-
FORM

R - 2, ITR-3, ITR-4, ITR-5, ITR-6, ITR-7, ITR-8 tranmitted electronically without digital
sinature] 2 0 1 0 - 1 1
V (Please see rule 12 of theIncome-tax Rules, 1962)
(Also see attached instructions)

Name PAN
PERSONAL INFORMATION AND THE

KAVITA DEVI - AGTPR3155Q

Flat/Door/Block No Name Of Date of Birth 22-12-
DATE OF ELECTRONIC

Premises/Building/Village 2008
TRANSMISSION

- - Senior Citizen
Form no. Which NO
has been
Road/Street/Post Office Area/Locality ITR - 1
electronically
SUNARON KA BAS - transmitted (fill the
code)
Town/City/District State Status (fill the code) 11
BARMER RAJASTHAN
Designation of Assessing ITO - BARMER Original or Revised ORIGINAL
Officer
E-filling(Ward/Circle)
Acknowledgement Date
Number
1 Gross total income (DD/MM/YYYY)
1 218,551.00
COMPUTATION OF FRINGE BENEFIT AND

2 Deductions under Chapter-VI-A 2 38,953.00

3 Total Income 3 179,598.00
4 Net tax payable 4 -
5 Interest payable 5 -
TAX THEREON

6 Total tax and interest payable 6 -

7 Taxes paid
a Advance Tax 7a -
b TDS 7b 8,000.00
c TCS 7c -
d Self Assessment Tax 7d -
e Total Taxes Paid (7a+7b+7c +7d) 7e 8,000.00
8 Tax payable (6-7e) 8 0.00
9 Refund (7e-6) 9 8,000.00
VERIFICATION
(Full name in block letters), son/
I KAVITA DEVI - daughter of
BABULAL holding permanent account number
AGTPR3155Q solemnly declare tht to the best of my knowledge and belief,
the information
the return and the schedules thereto which given in
have been transmitted electronically by
me vide acknowledgement number mentioned above is correct and complate and
that the amount of total income/ fringe benefites 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 and fringe benefits chargeable to income-tax for the
previous year relevant to the assessment year 2010-11. I futher declare that I am
and I am also competent to make this
making return
this and
return in verify it.
my capacity as

Sign Date 3-Feb-2011 Place

here
If the return of Income has been prepared by a Tax Return Preparer (TRP) give further details as below:
Identification No. of TRP Name Counter Signature
of TRP of TRP
For Office Use Only Seal and Signature of receiving offical

Receipt No.

Date
 Single copy ( to be sent to the ZAO)

Tax Applicable (Tick One) Assessment

Year
CHALLAN NO./ (0020) INCOME - TAX ON (0021) INCOME TAX a
ITNS 280 2010-2011
COMPANIES (OTHER THAN COMPANIES)
(CORPORATION TAX)

Parmenent Account Number

AGTPR3155Q
Full Name
KAVITA DEVI - DAUGHTER OF BABULAL
Complete Address with City & State
- SUNARON KA BAS
- BARMER 3 4 4 0 0 1

Type of Payment (Tick One)

Advance Tax (100) Surtax (102)
Self Assessment Tax (300) aTax on Distributed Profits of Domestic Companies(106)
Tax on Regular Assessment (400) Tax on Distributed Income to Unit Holders (107)

DETAILS OF PAYMENTS FOR USE IN RECEIVING BANK

Income Tax - Debit to A/c / Cheque credited on
Surcharge -
Education Cess - DD MM YY
Interest -
Penalty - SPACE FOR BANK SEAL
Others -
Total -
Total (in words) Rupees Only

Crore Lac Thousand Hundred Tens Units

Zero Zero Zero Zero

Paid in Cash/Debit to A/c/Cheque - Dated

Drawn on -
Name of the Bank and Branch)
Rs. -
Date 3-Feb-2011 Signature of person making payment

Taxpayers' Counterfoil (To be filled up by tax payer) SPACE FOR BANK SEAL

PAN AGTPR3155Q

Received from
KAVITA
(Name)

Cash/Debit to A/c/Chq. No. - For Rs. -

Rs.(in words)
Only
Drawn on -
(Name of the Bank and Branch)

on account of TAX ON OTHER THAN COMPANIES

Type of Payment SELF ASSESSMENT TAX Rs. -
Assesment Year 2010-2011