NAME OF CLIENT: APPENDIX IC NO.

(new) : INCOME FOR THE YEAR ENDED 31 DECEMBER 2011 YEAR OF ASSESSMENT 2011 SCHEDULE OF INFORMATION/DOCUMENTS REQUIRED (A) SOURCES OF INCOME SELF 1 Business income attach signed Profit and Loss Account and Balance Sheet 2 Partnership income attach signed Profit and Loss Account and Balance Sheet 3 Employment income attach Form EA/EC 4 Rental income :a. Particular of the property (please use separate sheet for more than 1 property) b. Gross rental received for the year c. Deductible expenses:- Quit rent - Assessment - Fire insurance - Bank loan interest (attach bank statement) - Agent commission (attach receipt) - Repair and maintenance (attach receipt) - Others (please specify) 5. Dividend income attach original dividend vouchers 6 Other income attach relevant income statement (B) CLAIM FOR TAX RELIEFS/REBATES 1 If married or divorced in the year 2011, please state:(a) Date of marriage or divorced: (b) Wifes / husbands name: (c) Wifes / husbands new & old I/C no. (d) Wifes / husbands income tax no.: Details of dependent children - for child born in year 2011, attach a copy of birth certificate - for disable child, attach relevant certificate Child over 18 years old Course Date Date of Name of school/ Attended commence Name of child birth college/university course WIFE REMARK

Annual amount expended

3 Insurance premium paid for the year 2011 attach copies of premium statement/receipt and if you have just purchased a new insurance policy, attach a copy of the information page of the policy. (a) Life insurance premium & EPF (max RM7,000) Name of insurance co. Policy no.

Self

Wife

2/-

-2 Effective from YA2010, an increased relief amount of RM1,000 (i.e. max RM7,000) is given solely in respect of annuity scheme premiums paid to insurance companies contracted with effect from 1 January 2010. The increased relief amount is also applicable to additional premiums paid on existing annuity schemes where payment commenced from 1 January 2010.

(b) Children education and medical (self and children) insurance premium (max RM3,000) Name of insurance co. Policy no. Self Wife

For item 4 to 16, please attach copies of receipts for our verification and ensure original receipts are available for tax audit purposes. Self Wife 4 Medical expenses for parents attach a copy of birth certification of yourself/spouse (max RM5,000) 5 Medical expenses for yourself, spouse and children for serious disease attach relevant medical report (max RM5,000 include RM500 for medical examination) 6 Expenses incurred for a complete medical examination for yourself, spouse or child (max RM500) 7 Expenses incurred for the purchase of supporting equipment for own use, or use by spouse, child or parent who is disable (max RM5,000) 8 Fees expanded on any course of study in any institution in Malaysia recognized by the Malaysian Government for acquiring technical, vocational, industrial, scientific, technological, law, accounting and Islamic financing skills or qualifications at tertiary level or any course of study for a degree at Master or Doctorate level (max RM5,000) 9 Purchase of personal computer (max RM3,000 every 3 years once) 10 Purchase of books, journals, magazines and other similar publications of enhancing knowledge for yourself, spouse or child (max RM1,000) 11 Purchase of sports equipment (max RM300) 12 Broadband subscription fees (max RM500) (only for YA2010 to 2012) 13 Net amount deposit into Skim Pendidikan Nasional for your children (max RM3,000) 14 Zakat / Fitrah payments and /or donations to approved institution 15 Total bi-monthly instalment payments (CP500) to the IRB attach IRB receipts 16 Total STD remitted by your employer to attached a confirmation of STD payment from your employer (slip jawapan) 17 Details of bank account (a) Name of bank (b) Bank account no.