INFORMATION

General Information for

Calculation & Submission of I.T. forms
Data is already filled in cell with YELLOW colour only in "INFO1", sheet, for
filling your data, filled in cell with YELLOW colour only in "INFO1" as per
given data. ( In BLUE cells only and only when necessary ). Any of this cell, if
you do not want to fill any information in "TEXT" format,than click "SPACE
BAR" in that cell. For information in NUMERICAL box when you do not want,
than "DELETE" that information.

5L/F S,Z JF/F ;[,DF\ lJUT EZ[, K[ T[ 5|DF6[ TDFZL lJUT ,FU] 50TF cc;[,cc DF\ NXF"JMP s
JFN/L S,ZGF ;[,DF\ OST H~ZLIFT CMI TM VG[ TM H lJUT EZM fPHIF DFlClT XaNGF
:J~5DF\ CMI VG[ T[ BFGFDF\ SM. lJUT EZJFGL YTL G CMI TM H[ T[ ;[,DF\ cc :5[;
AFZcc S,LS SZMP HIF VF\S0FSLI DFlClT G EZJFGL T[ ;[,DF\ c0L,[8cc S,LS SZMP

For printing of INCO, INCOTAX-P,FORM-16 and SARAL etc , select paper

size in print setup "GENERAL STANDARD FANFOLD 8.5 X 12" for dot matrix
printer & set "A-4" or "LEGAL" size for laser printer.
.gSM4 .gSM8[1Fv5L4 OMD"vGF\P!& VG[ ;Z, JU[Z[GF l5|g8L\U DF8[ l5|g8 ;[8
V5DF\ 5[5ZGL ;F.h 0M8 D[8=LS; 5|Lg8Z DF8[ ccHGZ, :8Fg00" O[GOM<0 (P5 2 !
Z .\Rcc VYJF HM ,[;Z 5|Lg8Z CMI TM ccV[v$cc VYJF cc,LU,cc ;L,[S8 SZMP
VG[ T[ 5|DF6[ ;[8L\U SZMP

Page 1 of 31
 INFORMATION

GENERAL INFORMATION
Surname First Name Father's Name Grand Father's Name

1 V8S 5MTFG]\ GFD l5TFG]\ GFD NFNFG]\ GFD

GRUNDY LEENABEN ALFREDBHAI THOMAS

2 Designation CMNMP SR.CLERK

Name Of Premises /
Flat/Door/Block No Road/Street/Post Office Area/Locality
Building / Village

O,[8 q a,MS G\AZ q 5|LDF.;L; q lAl<0\U ZM0 q X[ZL q V[ZLIF q ,MSF,L8LG]\

DSFG q UFD0FG]\ GFD 5M:8G]\ GFD GFD
3 W-3 OFFICER COLONY B/H CURKIT HOUSE

Town/City/District State Pin code

XC[Z q Ò<,FG]\ GFD ZFHIG]\ GFD 5LGSM0

VADODARA GUJARAT
GMSZLIFTGL S[8[UZL4 ;ZSFZL4 HFC[Z
Employer Category (Write "YES" YE
4 ;FC; S[ VgI H[ ,FU] 50T]\ CMI T[ BFGFDF\ Govt PSU
whichever applicable ) S
V\U|[ÒDF\ ccI;cc ,BMP
5 Sex D[, S[ OLD[, DF\YL ,FU] 50T]\ ,BMP FEMALE

6 Birth date HgD TFZLBP 8/22/1960

Telephone No. with STD No. / Mobile V[;P8LP0LP G\AZ ;FY[ OMG G\AZ
7
No. 0256-2438477
VYJF DMAF., G\AZP

8 Name of the Bank H[ A[\SDF\ BFT] CMI T[ A[\SG]\ GFDP ICICIBANK

9 MICR Code of the Bank

H[ A[\SDF\ BFT] CMI T[ A[\SGF
V[DVF.;LVFZ SM0
H[ A[\SDF\ BFT] CMI T[ A[\SG]\
10 Address of the Bank SAYAJIGUNJ,VADODARA
;ZGFD]\\P
11 Type of Account A[\SDF\ BFTFGM 5|SFZP SAVING

12 Account Number A[\SGF BFTFGF G\AZP 624501041413

13 Details of Credit Card : S|[0L8 SF0"GL lJUTP

14 Credit Card Number : S|[0L8 SF0"GF G\AZP

15 Issued by : S|[0L8 SF0" .:I] SZGFZGL lJUT

16 Parmanant Account No. (PAN No.) 5FG G\AZP ACBPG6501F

SR[ZL q BFTFGF J0FGM CMNMP s
17 Head of Office ( first ) DY.DIRECTOR
5C[,L SR[ZL f
18 Name of Office ( first ) SR[ZL q BFTFG]\ GFDP s 5C[,L SR[ZL f 913, E-BLOCK
SR[ZL q BFTFG]\ ;ZGFD]P s 5C[,L
19 Address of Office ( first ) KUBER BHAVAN
SR[ZL f
SR[ZL q BFT]\ HIF VFJ[, K[ T[ UFD
20 City of Office ( first ) VADODRA
S[ ;L8LP s 5C[,L SR[ZL f

21 Pin code 5LGSM0

SR[ZLGF 5FG q 8L0LV[; G\AZ VYJF

22 PAN NO.of Office ( first ) AAALD0251A
SR[ZLGF 8FG G\AZ P s 5C[,L SR[ZL f

SR[ZLGF 5FG q 8L0LV[; G\AZ VYJF

23 TAN NO.:- (of Office) ( first ) BRD01511G
SR[ZLGF 8FG G\AZ P s 5C[,L SR[ZL f

24 Head of Office ( second )

SR[ZL q BFTFGF J0FGM CMNMP s
ALÒ SR[ZL f
25 Name of Office ( second ) SR[ZL q BFTFG]\ GFDP s ALÒ SR[ZL f

SR[ZL q BFT]\ HIF VFJ[, K[ T[ UFD

26 City of Office ( second )
S[ ;L8LP s ALÒ SR[ZL f

27 Pin code 5LGSM0

SR[ZLGF 5FG q 8L0LV[; G\AZ VYJF

28 PAN NO.of Office ( second )
SR[ZLGF 8FG G\AZ P s ALÒ SR[ZL f

SR[ZLGF 5FG q 8L0LV[; G\AZ VYJF

29 TAN NO.:- (of Office) ( second )
SR[ZLGF 8FG G\AZ P s 5C[,L SR[ZL f

30 Name of Drawing Officer SR[ZLGF p5F0 VlWSFZLG]\ GFD C.P.PATEL

31 Name of Drawing Officer's father SR[ZLGF p5F0 VlWSFZLGF l5TFG]\ GFD

32 Designation of Drawing Officer SR[ZLGF p5F0 VlWSFZLGM CMNM Administrative Officer

33 Date Of Issuing of Form No. 16 OMD" G\AZ .:I] SIF"GL TFZLB 4/30/2011

VFJSJ[ZFGF ZL8G" ;FY[ HM0[, 5|

(1)
YD 0MSI]D[g8P

(2) ALHF 0MSI]D[g8G]\ GFDP

Document to be attached with return
34 ( To be attached with (3) +LHF 0MSI]D[g8G]\ GFDP
"SARAL" Form )
(4) RMYF 0MSI]D[g8G]\ GFDP

(5) 5F\RDF 0MSI]D[g8G]\ GFDP

(6) K99F 0MSI]D[g8G]\ GFDP

Summary of tax deducted at source

Acknowledgement no. of all Quarterly statement of TDS and VCL NZ +6 DF; GF VMOL; ãFZF EZJFDF\ VFJ[, ZL8G"GF
quarterly amount of tax deducted at source as well as tax ZL;L58 G\AZ T[DH NZ[S SD"RFZLGL H[ T[ l+DFl;S
deposited of the same employee S5FTGL ZSD T[DH EZFI[, ZSDGL lJUT ,BJLP
Recipt Numbers of original statement of
Amount of tax deduction in recipt of Amount of tax deposited remitted in
Quarter TDS under sub-section (3) of section
the employee respect of the employee
200
Quarter 1
Quarter 2
Quarter 3
Quarter 4
SR[ZL ;ZSFZL CMI TM V\U|[ÒDF\ Ò
If Government Office than write G or If
35 VG[ HM SR[ZL VW" ;ZSFZL CMI TM G
Semi Government Office than write S V\U|[ÒDF\ V[;
Are you P.H.? Than write here
VF5 XFZLZLS ZLT[ BM0 BF\56
36 WZFJTL jIlST s5LPV[RPf KM m TM VlC NO
YES
V\U|[ÒDF\ cI;c ,BMP
XFZLZLS ZLT[ BM0 BF\56 WZFJTL
37
Special Deduction for P.H. ( upto Rs.
50000/-)
jIlSTG[ D/T]\ :5[P0L0SXG s~FP 5____qv
GL DIF"NFDF\fP
0.00
HM TD[ ;LGLIZ ;L8LhG CM TM VCL V\U|
If you are Senior Citizen than,write "YES"
38 here,(If you are 65 year old on 31-3-2008) [ÒDF\ I; ,BMPsTFP#!v_#vZ__( ;]WLDF\ &5 NO
JQF"GL p\DZf

INFORMATION ABOUT INCOME ( FROM PAY)

39 Band Pay of March-2010 DFR"vZ_!_ GM A[g0 5[ VCL ,BMP 14470.00
40 Grade Pay of March-2010 DFR"vZ_!_ GM U|[0 5[ VCL ,BMP 4200.00
MAR 27 APR 27 MAY 35
VCL AFH]GF SMQ8SD\F\
41 Rate of D.A. ( % , Percentage)
0LPV[PGF 8SF s@f ,BM\P
JUL 35 AUG 35 SEP 35
NOV 45 DEC 45 JAN 45
42 Rate of Special Pay :5[XLI, 5UFZ D/TM CMI TM T[GM NZP 125.00
H.R.A. %, 30 OR 20 OR 10 3ZEF0FGM NZ H[D S[ #_4 Z_4 !_ VYJF
43
OR 0 (If living in Qtr.) _ sX}gIfsNZ[S V\U|[ÒDF\f 0.00
44 Medical Allowance D[0LS, EyYFGM NZP 100.00
45 Washing Allowance WM,F. E\yY] D/T]\ CMI TM T[GM NZP 0.00
46 Vehicle Allowance (T.A.)] JFCG EyYFGM NZP s 8LPV[Pf 400.00
47 City Allowance ;L8L V[,Fpg; D/T]\ CMI TM T[GM NZP 240.00
TDG[ SM. :5[xI, EyY]\ NZ DF;\ D/T]\ MAR
0 APR 0 MAY 0
Name of other special allowance CMI TM T[ EyYFG]\ GFD V\U|[ÒDF\
and Monthly details. ATFJ[, ;[,DF\ ,BMP EyYFGM NZ
48 JUL 0 AUG 0 SEP 0
NZ[S DF;GF ;[,DF\ ,BMP
Cash Allowance NOV 0 DEC 0 JAN 0

1 ST D.A. CALCULATION
Amount of D.A. Arrears (Total from First 5|YD K DF; NZdIFG D/[, DM\3JFZL
49A
6 Month ) E\yYFGF TOFJTGL ZSDP 5976.00

5|YD K DF; NZdIFG D/[, DM\3JFZL

Amount deducted of "Proffetional Tax"
49B
from First D.A. Arrears
E\yYFGF TOFJTGL ZSDDF\YL 0.00
jIJ;FIJ[ZFGL YI[, S5FTP
5|YD K DF; NZdIFG JQF" NZdIFG D/[,
Amount Paid in Cash from First D.A.
49C
Arrears
DM\3JFZL E\yYFGF TOFJTGL 1494.00
ZSDDF\YL S[XDF\ R]SJFI[, ZSDP

5|YD K DF; NZdIFG D/[, DM\3JFZL

Amount credited to "GPF" from First
49D
D.A. Arrears
E\yYFGF TOFJTGL ZSDDF\YL 4482.00
ÒP5LPV[OPDF\ HDF SZJF5F+ ZSDP

2 ND D.A. CALCULATION
Amount of D.A. Arrears (Total from ALHF K DF; NZdIFG D/[, DM\3JFZL
50A
Second 6 Month ) E\yYFGF TOFJTGL ZSDP 5772.00
ALHF K DF; NZdIFG D/[, DM\3JFZL
Amount deducted of "Proffetional Tax"
50B
from Second D.A. Arrears
E\yYFGF TOFJTGL ZSDDF\YL 0.00
jIJ;FIJ[ZFGL YI[, S5FTP
ALHF K DF; NZdIFG JQF" NZdIFG D/[,
Amount Paid in Cash from Second D.A.
50C
Arrears
DM\3JFZL E\yYFGF TOFJTGL 0.00
ZSDDF\YL S[XDF\ R]SJFI[, ZSDP
ALHF K DF; NZdIFG D/[, DM\3JFZL
Amount credited to "GPF" from Second
50D
D.A. Arrears E\yYFGF TOFJTGL ZSDDF\YL 5772.00
ÒP5LPV[OPDF\ HDF SZJF5F+ ZSDP
Other Arears if any give detail below
JQF" NZdIFG D//, VgI V[ZLI;" q
51A Other Arrears (Total of all other Arrears)
TOFJTGM ;ZJF/M VCL ,BM\P 36170.00
Amount deducted of "Proffetional Tax" JQF" NZdIFG D/[, VgI V[ZLI;" q
51B from Other Arrears (Total of all other TOFJTGL ZSDDF\YL jIJ;FIJ[ZFGL YI[, 0.00
Arrears) S5FTP
Amount deducted of "Group Insurance" JQF" NZdIFG D/[, VgI V[ZLI;" q
51C from Other Arrears (Total of all other TOFJTGL ZSDDF\YL ;ZSFZL lJDFGL 0.00
Arrears) GL YI[, S5FTP
Amount deducted of "Income Tax" from JQF" NZdIFG D/[, VgI V[ZLI;" q
51D Other Arrears (Total of all other TOFJTGL ZSDDF\YL VFJSJ[ZFGL YI[, 0.00
Arrears) S5FTP
JQF" NZdIFG D/[, VgI V[ZLI;" q
Amount Paid in Cash from Other
51E
Arrears (Total of all other Arrears) TOFJTGL ZSDDF\YL S[XDF\ R]SJFI[, 36170.00
ZSDP
JQF" NZdIFG D/[, VgI V[ZLI;" q
Amount credited to "GPF" from Other
51F
Arrears (Total of all other Arrears) TOFJTGL ZSDDF\YL ÒP5LPV[OPDF\ 0.00
HDF SZJF5F+ ZSDP
52 Bonus AMG; D/T]\ CMI TM T[GL ZSDP 0.00
Amount of Bonus Credited to G.P.F. (If D/[, AMG; 5{SLGL ÒP5LPV[OPDF\ HDF
53
any) SZJF5F+ ZSDP 0.00
5ZL1FF S[ VgI SM. JWFZFGL
54 Remunration(Total of all Remunrations) SFDULZL ;AA DC[GTF6]\ D/[, CMI TM 0.00
T[GM S], ;ZJF/MP
ZHF ZMS0 EyY]\ ,LW[, CMI TM T[GL
55 Leave Surrendar
ZSDP 0.00
ZHF 5|JF; ZFCTGL H[ ZSD D/[, CMI T[
56 L.T.C.( if actually enjoyed) s HM BZ[BZ 5|JF; SZ[, CMI VG[ D/[, CMI 0.00
TM HfP

INFORMATION ABOUT INCOME ( FROM OTHER SOURCES)

57 Bank Intrest
58 N.S.C. Interest ( Series-8)
59 N.S.S.( Scheme-1987)
60 N.S.S. Interest ( Scheme-1992)
61 Income from Minor Children
62 Jivansuraksha Pension Fund
Contribution of Central Government to
New Employee join in new Pension
63
Scheme of Central Government after
01-01-2004 and join in .
64 L.I.C. Jivandhara
65 L.I.C. Jivanakshay
66 E.L.S.S.
67 Tution Income
68 Any other Income
INFORMATION ABOUT INVESTMENT
69 House Rent Actually paid (Yearly)
H.B.A. Interest as per Rule 24(2),
100% Upto Rs.30,000/-, ( If Loan
senction before 1-4-99) and after
1-4-99, if House purchased or
70
Completed Construction within
three years of senctioin of loan,
than 100 % Upto Rs. 1,50,000/-.
(Enter as per condition )
Investment in Jivansuraksha Pension
71
Fund
Investment any Pension Scheme of
Central Government ( Concerned with
72
new employee employed after 01-01-
2004)
73 A Medi Claim Primium
73 B If parents are Senior Citizen than,write;L8LhG
73 C Medi Claim Primium for parents
Medical Expenses done for P.H.
74
Dipendable Person
Medical Expenses done for Dangerous JQF" NZdIFG S[g;Z H[JF U\ELZ ZMUM
75 Deases like Cancer (pto limit Rs. DF8[ SZ[, TALAL BR" s~FP $____qvGL
40000/- ) DIF"NFDF\fP
Intrest of loan taken for Higher
76
Education
Deduction under Section 80-G for C.M.
77
Fund,P.M.Fund
Deduction under Section 80-G
78 otherthan C.M. Fund,P.M.Fund (other
donation)
A[\SG]\ jIFH D/[, CMI TM T[GL ZSDP 0.00
VUFpGF JQFM"DF\ ZFQ8=LI ART 5+MDF\
ZMSF6 SZ[, CMI TM T[GF D/JF5F+ jIFHGL 0.00
U6TZL SZL T[GL S], ZSDP
V[GPV[;PV[;Ps:SLDv!)(*fGL D/[, ZSDP 0.00
V[GPV[;PV[;Ps:SLDv!))ZfG]\ D/[, jIFH 0.00
;ULZ AF/SGL VFJSP 0.00
ÒJGWFZF 5[gXG O\0DF\YL 5M,L;L
;Zg0ZGL D/[, ZSDP 0.00
_!v_!vZ__$ 5KL S[gã ;ZSFZGF SD"RFZL
TZLS[ HM0FI[, CMI VG[ GJL 5[gXG
IMHGFDF\ H[ S5FT YTL CMI T[DF\ S[gã 0.00
;ZSFZ ãFZF pD[ZJFDF\ VFJ[, OF/FGL ZSDP
V[,PVF.P;LP ÒJGWFZFGL D/[, ZSDP 0.00
V[,PVF.P;LP ÒJGV1FIGL D/[, ZSDP 0.00
.PV[,PV[;PV[;PGL D/[, ZSDP 0.00
8I]XGGL VFJSGL D/[, ZSDP 0.00
VgI SM. ;ZSFZL VFJSGL D/[, ZSDP 0.00
EF0FGF DSFGDF\ ZC[TF CMI TM
R}SJ[, S], JFlQF"S EF0FGL ZSDP 0.00
DSFG 5[XULG]\ JQF" NZdIFG EZ[, jIFHGL
S], ZSD sHM ,MG TFP_!q_$q!))) 5C[,F
D\H]Z YI[, CMI TM ~FP #____qv ;]WL !__
@ VG[ sHM ,MG TFP_!q_$q!))) 5KL D\H]Z 8649.00
YI[, CMI VG[ S\g:8=SXG +6 ;F,DF\ 5}6"
SZ[, CMI TM ~FP !5____qv ;]WL !__ @ f
ÒJGWFZF 5[gXG O\0DF\ SZ[, ZMSF6P 0.00
S[gã ;ZSFZGL SM.56 5[gXG :SLDDF\
SZ[, ZMSF6P s _!v_!vZ__$ 5KL ;ZSFZL
GMSZLDF\ GJL :SLD C[9/ NFB, YI[, 0.00
SD"RFZLVM DF8[ GL f
JQF" NZdIFG D[0L S,[DDF\ SZ[, S],
ZMSF6P 0.00
HM TDFZF DFTFl5TF ;LGLIZ
CMI TM VCL V\U|[ÒDF\ I;
"YES" here, NO
,BMP
JQF" NZdIFG D[0L S,[D DFTF l5TF
DF8[ SZ[, S], ZMSF6P 0.00
JQF" NZdIFG lJS,F\U VFlzT DF8[ SZ[,
TALAL BR"GL ZSDP 0.00
0.00
GF6FSLI ;\\:YF S[ DFgI WDF"NF ;BFJTL
;\:YF 5F;[YL prRTZ S[/J6LGF C[T];Z
,LW[, ,MGGF jIFHGL SZ[, R]SJ6LGL 0.00
ZSD
JQF" NZdIFG ;[SXG (_vÒ C[9/ ;LPV[DP
S[ 5LPV[DP O\0DF\ VF5[, NFGGM S], 0.00
;ZJF/FGL ZSDP
JQF" NZdIFG ;[SXG (_vÒ C[9/ ;LPV[DP
S[ 5LPV[DP O\0DF\ VF5[, NFG l;JFIGL 0.00
VgI ;\:YFG[ VF5[, NFGGL S], ZSDP

JQF" NZdIFG 5LP5LPV[OPDF\ SZ[, S],

79 P.P.F.
ZMSF6P
0.00
JQF" NZdIFG ÒJG JLDFs
80 L.I.C. Primium V[,PVF.P;LPfDF\ SZ[, S], ZMSF6GL 3892.00
ZSDP
JQF" NZdIFG5M:8, ÒJG JLDF DF\ SZ[,
81 P.L.I. Primium
S], ZMSF6GL ZSDP 0.00
5UFZDF\YL S5FT YTF U|]5
82 Group Insurance .g:I]Zg;GF 5|lTDF;GF NZGL 100.00
ZSDP
JQF" NZdIFG I]PV[,PVF.P5LPDF\ SZ[,
83 Investment done in U.L.I.P.
S], ZMSF6GL ZSDP 0.00

JQF" NZdIFG 5MQ8 VMOL;GL

84 Post office CTD ( 10 OR 15 Year )
;LP8LP0LPDF\ SZ[, S], ZMSF6GL ZSDP 0.00
JQF" NZdIFG ZFQ8=LI ART 5+M
85 N.S.C. ( Series-8) sV[GPV[;P;LPf DF\ SZ[, S], ZMSF6GL 0.00
ZSDP
VUFpGF JQFM"DF\ ZFQ8=LI ART
N.S.C. Interest as reinvestment 5+MDF\ ZMSF6 SZ[, CMI TM T[GF
86
( Series-8) D/JF5F+ jIFH 5{SLGL 5]Go ZMSF6DF\ 0.00
U6TZL SZJF5F+ ZSDP
DSFG 5[XUL ,LW[, CMI TM T[GL JQF"
87 H.B.A.Principal
NZdIFG EZ[, D}/ sS],f ZSDP 72038.00
JQF" NZdIFG V[GPV[;PV[;P
88 N.S.S. (Scheme-1992) GL !))ZGL :SLDDF\ SZ[, S], ZMSF6GL 0.00
ZSDP
JQF" NZdIFG V[,PVF.P;LPGL
89 L.I.C. JIivandhara Premium ÒJGWFZF :SLDDF\ SZ[, S], ZMSF6GL 0.00
ZSDP
JQF" NZdIFG V[,PVF.P;LPGL
90 L.I.C. Jivanakshay Premium ÒJGV1FI :SLDDF\ SZ[, S], ZMSF6GL 0.00
ZSDP

Invesment in long term S[gã ;ZSFZ ãFZF GM8LOFI

SZ[, ,F\AF UF/FGF .gOF:8|SRZ
91
infrastructure bond notified by
central government ( Limit upto AMg0DF\ SZFI[, ZMSF6 s 0.00
Rs. 20000/-)
~FPZ____qv GL DIF"NFDF\f
Investment in units of E.L.S.S. JQF" NZdIFG .PV[,PV[;PV[;PGF
92
(Limit upto Rs. 10000/-) I]GL8DF\ SZ[, S], ZMSF6GL ZSDP 0.00
Investment in Share or Debenture .gO|F:8=SRZ4 5FJZ S[ 8[,L
93 of Infrastructure, Power or SMdI]GLS[XGGF X[Z S[ 0LA[gRZDF\ 0.00
Teli Communication Company SZ[, S], ZMSF6GL ZSDP
JQF" NZdIFG CMD ,MG :SLDDF\ SZ[,
94 Investment in Home Loan Ssheme
S], ZMSF6GL ZSDP 0.00

Children's tution fee for one child or two JQF" NZdIFG V[S S[ A[ AF/S DF8[ EZ[,
95
Children lX1F6 OLGL ZSDP 0.00

JQF" NZdIFG VgI SM. ZMSF6 SZ[, CMI

96 Other investment if any
TM T[GL S], ZMSF6GL ZSDP 0.00

;[SXG () C[9/ D/JF5F+

97 Relief Under section 89
K]8KF8GL lJUT 0.00

SOME OTHER DETAILS AND

Incom-tax
CALCULATIONS
Amount of D.A. in
G.P.F. deducted
Month deducted per G.P.F. deducted per
per month
month month
5|lT DF; DM\3JFZL
VFJS J[ZFGL ÒP5LPV[OP S5FT
DF; EyYFGL ÒP5LPV[OPDF\
S5FT 5|lT DF; 5|lT DF;
HDF SZJF 5F+ ZSD
Mar-10 0.00 5000.00 2054.00
AFH]DF\ VF5[,F
SMQ8SDF\ 5|lT Apr-10 0.00 6000.00 0.00
DF;GL VFJS
J[ZFGL S5FT May-10 0.00 6000.00 0.00
T[DH Jun-10 0.00 6000.00 0.00
ÒP5LPV[OPGL
S5FTGL ZSD Jul-10 0.00 6000.00 0.00
In the table
NXF"JMP
given beside , Aug-10 0.00 6000.00 0.00
DM\3JFZL
enter the
EyYFGL Sep-10 0.00 6000.00 0.00
###

amount of
ÒP5LPV[OPDF\
Incomtax and HDF SZJF5F+ Oct-10 0.00 6000.00 0.00
G.P.F.
ZSD 56 Nov-10 0.00 6000.00 0.00
deducted per AFH]DF\
month. NXF"JJFDF\ Dec-10 0.00 6000.00 0.00
VFJ[, K[P Jan-11 0.00 6000.00 0.00

Page 2 of 31
 INFORMATION

In the table
given beside ,
enter the
###

amount of
Incomtax and
G.P.F.
deducted per
month.

See cell No.J 97 of sheet

INCOTAX-P For the entry to be
done here
Feb-11
VCL SZJFGL V[g8=L 6000.00 0.00
DF8[ INCOTAX-P
GF J 97 G\AZGF ;[,DF\ SZMP

Detail information about deduction of tax at source for form No. 16

GLR[GL lJUT H[6[ VFJSJ[ZM EZ[, CMI T[GL S5FTGL lJUT OMD" GF\P !& DF\ NXF"JJF DF8[ EZJLP
Details of Tax Deducted and Deposited into Central Government Account .
DDO Sequence Number in the Book
Sr.No. Receipt numbers of form no. 24 G Date on which tax Deposited
Adjustment Mini Statement
Mar-10

Apr-10

May-10

Jun-10
###

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Details of income from House Property

W-3, OFFICER COLONY, B/H CURKIT
100 Address of property 1 DSFG q 5|M58L" G]\ ;ZGFD]\
HOUSE
101 Town / City 1 DSFG q 5|M58L" G]\ UFD VADODARA
DSFG q 5|M58L" H[ ZFHIDF\
102 State 1 GUJARAT
CMI T[ ZFHIG]\ GFD
103 PIN code 1 5LGSM0 0
HM DSFG q 5|M58L"
If let out ? Than write here YES
104 EF0[ VF5[, CMI TM VCL NO
1 HM DSFG qcI;c
5|M58L"
V\U|[ÒDF\ ,BMP
105 Name of Tenant 1 EF0[DSFG
HM VF5[, qCMI TM VCL
5|M58L"
EF0[
EF0[ ZFBGFZG]\
VF5[, CMI TMGFD ,BMP
VCL
106 PAN of Tenant (optional ) 1
EF0[ ZFBGFZGF 5FG
Annual letable value / rent
G\AZ ,BMP
HM DSFG q 5|M58L"
received or receivable ( Higher if
107
let out for whole of the year, lower if EF0[ VF5[, CMI TM VCL 0.00
let out for part of the year. ) 1 JFlQF"S EF0FGL VFJS ,BMP
The amount of rent which cannot
108
be realized 1 0.00

109 Tax paid to local authorities. 1 0.00

Details of Tax Deducted at Source on Interest [As

per Form 16 A issued by Deductor(s)]
Tax Deduction Account
Sr Name and address of the Amount paid / Credit Date of Payment / Total tax Amount out of (6) claimed
Number (TAN) of the
No. Deductor Credit deposited for this year
Employer
i

ii

Details of Tax Deducted at Source on Interest [As

per Form 16 A issued by Deductor(s)]
Tax Deduction Account Date of
Sr Amount paid / Amount out of (6) claimed
Number (TAN) of the Name and address of the Deductor Credit
Payment / Total tax deposited
No. Credit for this year
Employer
(1) (2) (3) (4) (5) (6) (7)

i 0

ii 0

iii 0

ANNEXURE - B
Details of Tax Deducted and Deposited in the Central Government Account through Challan.
( The Employer to provide payment wise details of tax Deducted and Deposited withrespect to the employee ).

Tax Deposited in Challan Identification Number (CIN)

Sr.
Name of Bank & Branch respect on of the BSR Code of the Bank Date on which tax
No. Challan Serial Number
employee (Rs.) Branch Deposited

1
2

3
4

Note Enter the totals of Advance tax and Self Assessment tax in Sl No. 15 a and 15c of TAXES PAID

Return filed under Section -

i Voluntarily before the due date
ii voluntarily after the due date
iii In response to notice under section 142 (1)
iv In response to notice under section 148
v In response to notice under section 153 A
3 Ward No. of Incomtax Office. I.T.O., WARD NO. 4(2) .gSD 8[1F VMOL;GF JM0" G\AZ

Page 3 of 31
 GRUNDY LEENABEN ALFREDBHAI
913, E-BLOCK
VADODRA

D. A. Calculation First

Rate of D.A. 1/1/2010 to 4/30/2010 New 35

Period Band Pay Grade Pay Total of 2 & 3 D.A To be pay D.A paid

1 2 3 4 5 6

Jan-10 14470 4200 18670 6535 5041

Feb-10 14470 4200 18670 6535 5041

Mar-10 14470 4200 18670 6535 5041

Apr-10 14470 4200 18670 6535 5041

57880 16800 74680 26140 20164

D. A. Calculation Second

Rate of D.A. 7/1/2010 to 12/31/2010 New 45

Period Band Pay Grade Pay Total of 2 & 3 D.A To be pay D.A paid

1 2 3 4 5 6

Jul-10 15040 4200 19240 8658 6734

Aug-10 15040 4200 19240 8658 6734

Sep-10 15040 4200 19240 8658 6734

45120 12600 57720 25974 20202

BHAI

Old 27
Diff to be Amount in Amount
pay G.P.F. in Cash
7 8 9

1494 1494 0

1494 1494 0

1494 1494 0

1494 0 1494

5976 4482 1494

Old 35
Diff to be Amount in Amount
pay G.P.F. in Cash
7 8 9

1924 1924 0

1924 1924 0

1924 1924 0

5772 5772 0
 913, E-BLOCK, VADODRA
INCOME YEAR :- 2010-2011 ASSESSMENT YEAR:- 2011-2012

NAME:- GRUNDY LEENABEN ALFREDBHAI DESIGNATION :- SR.CLERK

Name of Cash
Sr.No. Description Basic Pay Grade Pay Total Sp. Pay D.A. H.R.A. M.A. W.A. T.A. C.L.A Total P.T. G.I. G.P.F. I.T.DED
the Month Allowance

1 Mar-2010 Pay 14470.00 4200.00 18670.00 125.00 5041.00 0.00 100.00 0.00 400.00 240.00 0.00 24576.00 200.00 100.00 7054.00 0.00
2 Apr-2010 Pay 14470.00 4200.00 18670.00 125.00 5041.00 0.00 100.00 0.00 400.00 240.00 0.00 24576.00 200.00 100.00 6000.00 0.00
3 May-2010 Pay 14470.00 4200.00 18670.00 125.00 6535.00 0.00 100.00 0.00 400.00 240.00 0.00 26070.00 200.00 100.00 6000.00 0.00
4 Jun-2010 Pay 14470.00 4200.00 18670.00 125.00 6535.00 0.00 100.00 0.00 400.00 240.00 0.00 26070.00 200.00 100.00 6000.00 0.00
5 Jul-2010 Pay 15040.00 4200.00 19240.00 125.00 6734.00 0.00 100.00 0.00 400.00 240.00 0.00 26839.00 200.00 100.00 6000.00 0.00
6 Aug-2010 Pay 15040.00 4200.00 19240.00 125.00 6734.00 0.00 100.00 0.00 400.00 240.00 0.00 26839.00 200.00 100.00 6000.00 0.00
7 Sep-2010 Pay 15040.00 4200.00 19240.00 125.00 6734.00 0.00 100.00 0.00 400.00 240.00 0.00 26839.00 200.00 100.00 6000.00 0.00
8 Oct-2010 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
9 Nov-2010 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
10 Dec-2010 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
11 Jan-2011 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
12 Feb-2011 Pay 15040.00 4200.00 19240.00 125.00 8658.00 0.00 100.00 0.00 400.00 240.00 0.00 28763.00 200.00 100.00 6000.00 0.00
13 D.A. Arrears 1 5976.00 5976.00 0.00 0.00 4482.00 0.00
14 D.A. Arrears 2 5772.00 5772.00 0.00 0.00 5772.00 0.00
15 Other Arrears 36170.00 36170.00 0.00 0.00 0.00 0.00
16 Bonus 0.00 0.00 0.00
17 Remunretion 0.00 0.00
18 Leave Surrender 0.00 0.00
19 L.T.C. 0.00 0.00
20
TOTAL 178200.00 50400.00 228600.00 1500.00 98392.00 0.00 1200.00 0.00 4800.00 2880.00 36170.00 373542.00 2400.00 1200.00 83308.00 0.00
ANY OTHER INCOME (ACCEPT SALARIES TO BE DECLARED SHOW HERE ( LIKE INTEREST,DIVIDEND, ETC)
Bank Intrest 0.00 L.I.C. Jivandhara 0.00
N.S.C. Interest ( Series-8) 0.00 L.I.C. Jivanakshay 0.00
N.S.S.( Scheme-1987) 0.00 E.L.S.S. 0.00
N.S.S. Interest ( Scheme-1992) 0.00 Tution Income 0.00
Income from Minor Children 0.00 Any other Income 0.00
Jivansuraksha Pension Fund 0.00 Income from House Property. 0.00
Contribution of Central Government 0.00

( GRUNDY LEENABEN ALFREDBHAI )

Total other Income 0.00 GROSS INCOME 373542.00 SIGNATURE OF GOVT.SERVANT
 STATEMENT OF INCOME TAX

913, E-BLOCK, VADODRA

INCOME YEAR : 2010-2011 ASSESSMENT YEAR : 2011-2012

NAME : GRUNDY LEENABEN ALFREDBHAI

DESIGNATION : SR.CLERK

PAN NO. : ACBPG6501F SEX : FEMALE

Divison ( A ) Income from Salary :
"(1) Gross income from salary : as per rule 17 Rs. 373542.00

"(2) Deduction of allowances under section (10)

(a) House rent allowance as per rule 10 (13-A)
( i ) H.R.A. Actually paid as per Bill ( Annualy) Rs. 0.00
( ii ) If the amount actually paid as a rent is > Rs. 0.00
10 % Amount of Basic + D.A. Than ( A - B )
( A ) Actual Paid H.R.A. Rs. 0.00
( B ) 10 % of ( Pay + D.A. ) Rs. 0.00
( iii ) 40 % of ( Pay + D.A. ) Rs. 0.00
( iv ) Net elligible deduction of H.R.A.(Out of 1,2 OR 3 whichever is Minimum) Rs. 0.00
(b) Under Rule 10(14)(i)Rule 2,BB(i),Dress WASHING ALLOWNCE Paid (100 %) Rs. 0.00

(c) Under Rule 10(14)(ii)Rule 2,BB(ii)TRANS.ALLOWANCE,( 1->100 % Upto limit of Monthly Rs. 4800.00
Rs. 800/-) And ( 2->100 % Upto limit of Monthly Rs. 1600/- For P.H. Employee)
(d) Total of (a)+(b)+(c) ( Allowances to be deducted Under Rule 10) Rs. 4800.00

"(3) Deduction under rule As per Rule 16(3), PROFESSIONAL TAX ( 100 % ) Rs. 2400.00
"(4) Deduction under rule As per Rule 16(5), L.T.C. Rs. 0.00
A Remaining Salary Income (Column : 1-2(d)-(3) Rs. 366342.00

Division ( B ) Income from other sources :

"(1) Bank Intrest Rs. 0.00
"(2) N.S.C. Interest ( Series-8) Rs. 0.00
"(3) N.S.S.( Scheme-1987) Rs. 0.00
"(4) N.S.S. Interest ( Scheme-1992) Rs. 0.00
"(5) Income from Minor Children Rs. 0.00
"(6) Jivansuraksha Pension Fund Rs. 0.00
"(7) Contribution of Central Government Rs. 0.00
"(8) L.I.C. Jivandhara Rs. 0.00
"(9) L.I.C. Jivanakshay Rs. 0.00
"(10) E.L.S.S. Rs. 0.00
"(11) Tution Income Rs. 0.00
"(12) Any other Income Rs. 0.00
"(13) Income from House Property. Rs. 0.00
"(14) Total Other Income [ Column (1) to (12) Rs. 0.00
B Total gross income ( Salary + Other Income [ A + DIV. B( 14 )]) Rs. 366342.00
Division ( C ) deduction admissible from total gross income
Description Invesment Eligible
"(1) LESS : H.B.A. Interest as per Rule 24(2), 100% Upto Rs.30,000/-,( If Loan senction Rs. 8649.00 Rs. 8649.00
before 1-4-99) and after 1-4-99, if House purchased or Completed Construction within
three years of senctioin of loan, than 100 % Upto Rs. 1,50,000/-.
"(2) As per Rule 80-CCC. Jivansuraksha Pension Fund ( Limit Upto Rs. 100000.00) Rs. 0.00 Rs. 0.00

"(3) As per Rule 80-CCD. Investment in any Pension Scheme of Central Government Rs. 0.00 Rs. 0.00
( Concerned with new employee employed after 01-01-2004)

Page 7 of 31
 STATEMENT OF INCOME TAX
"(4) As per Rule 80-C ( Limit Upto Rs. 110000.00) but less of 80-CCC & 80-CCD
(i) G.P.F./ C.P.F. Rs. 83308.00
(ii) P.P.F. Rs. 0.00
(iii) L.I.C. Premium Rs. 3892.00
(iv) P.L.I. Premium Rs. 0.00
(v) Group Insurance Rs. 1200.00
(vi) Investment in U.L.I.P. Rs. 0.00
(vii) Post Office C.T.D. ( 10 Or 15 Year ) Rs. 0.00
(viii) N.S.C. (Series - 8 ) Rs. 0.00
(ix) N.S.C.Interest as Reinvestment Rs. 0.00
(x) H.B.A.Principal Rs. 72038.00
(xi) N.S.S. (Scheme-1992) Rs. 0.00
(xii) L.I.C. Jivandhara Premium Rs. 0.00
(xiii) L.I.C. Jivanakshay Premium Rs. 0.00
(xiv) E.L.S.S. Unit Investment Rs. 0.00
(xv) Investment in Share or Debenture of Infrastructure,Power or Teli Communication Company. Rs. 0.00
(xvi) Investment in Home Loan Scheme Rs. 0.00
(xvii) Tution fee paid for children Rs. 0.00
(xviii) Other elligible if any Rs. 0.00
Total of (i) TO (xviii) Rs. 160438.00
Description Invesment Eligible
Total of ( 80-C ) + ( 80-CCC ) + ( 80-CCD ) Rs. 160438.00
"(5) Net Deduction under section 80-CCE Rs. 100000.00
"(6) Under section 80-D, Mediclaim Premium ( Upto Rs. 15,000.00, but Rs.20,000.00 for Rs. 0.00 Rs. 0.00
ceniyor citizen )
"(6) Under section 80-D, Mediclaim Premium for parents ( Upto Rs. 15,000.00 but Rs. 0.00 Rs. 0.00
Rs.20,000.00 If they are ceniyor citizen)
"(7) Under section 80-DD, Medical Expenses done for P.H. dipendable personal relative Rs. 0.00 Rs. 0.00
"(8) Under section 80-DDB,Medical Expense done for Dangerous deases like Cancer (Upto Rs. Rs. Err:504
0.00
Rs. 40000.00). If the person is senior citizen, than upto Rs. 60000.00.
"(9) Under section 80-E,Intrest of loan taken for higher Education for 7 year from starting Rs. 0.00 Rs. 0.00
"(10) Under section 80-CCF, Investment in Infrastructure bond notified by central Rs. 0.00 Rs. 0.00
government
"(11) Under section 80-G,Donation like C.M. Fund, P.M. Fund or other Donations Rs. 0.00 Rs. 0.00
"(12) As Per Rule 80-U,Special Deduction to P.H. & Blind employee ( Upto Rs. 50,000/- ) Rs. 0.00 Rs. 0.00
"(13) Total of amount to be deducted of Division (C) [(1)+(5)+(6)+(7)+(8)+(9)+(10)+(11) Rs. Err:504
Less Income [ Division : B - Division : C(12) ] Rs. Err:504
Remaining Amount Rounded to Rs.10/- ( Ten) Rs. Err:504
DIivision : E Calculation of Income Tax
General Women Ciniyer Citizen Tax Amount Tax
"(1) Upto Rs. 160000/- Upto Rs. 190000/- Upto Rs. 240000/- 0% Err:504 Rs. 0.00
"(2) 160001 TO 500000/- 190001 TO 500000/- 240001 TO 500000/- 10% Err:504 Rs. Err:504
"(3) 500001 TO 800000/- 500001 TO 800000/- 500001 TO 800000/- 20% Err:504 Rs. Err:504
"(4) 800001/- to onward 800001/- to onward 800001/- to onward 30% Err:504 Rs. Err:504
Total amount of Tax : Rs. Err:504
Adjustment of Income Tax
Amount of Income Tax Rs. Err:504
2 % education surcharge + 1 % SEC & HSEC surcharge Rs. Err:504
Less Relief Under section 89 0.00
Net amount of Income Tax Rs. Err:504
Details of Income Tax paid or to be pay
1 Recovered Upto JANU-2011 Rs. 0.00
2 To be recovered from pay of FEB-2011 Rs. Err:504
3 Recovered from pay of FEB-2011 Rs. 0.00
4 Total Income-Tax paid Rs. 0.00

Page 8 of 31
 STATEMENT OF INCOME TAX

Certificate by employee

This is to certify that the information given in this statement is true and mistake
less.

( GRUNDY LEENABEN ALFREDBHAI )

Signature of Govt. Servant

Certificate by office

This is to certify that the information given in this statement compared with office
record as well as documents presented by employee and found correct.

Signature and seal of Head of Office

Page 9 of 31
 FORM NO.:-16
[See Rule 31(1)(a)]

PART-A

Certificate under Section 203 of the Income-Tax act,1961 for the tax deducted at source on "SALARIES".
Name and Address of the Employer Name & Designation of the Employee

DY.DIRECTOR 913, E-BLOCK GRUNDY LEENABEN ALFREDBHAI

KUBER BHAVAN SR.CLERK

VADODRA 913, E-BLOCK, VADODRA

PAN of the Deductor TAN of the Deductor PAN of the Employee

AAALD0251A BRD01511G ACBPG6501F

CIT (TDS) Assessment Year PERIOD

FROM TO
Address
2011-2012
City Pin Code
4/1/2010 3/31/2011
Summary of tax deducted at source
Recipt Numbers of original statement of Amount of tax deduction in Amount of tax deposited remitted
Quarter
TDS under sub-section (3) of section 200 respect of the employee in respect of the employee

Quarter 1 0 0.00 0.00

Quarter 2 0 0.00 0.00

Quarter 3 0 0.00 0.00

Quarter 4 0 0.00 0.00

PART-B ( Refer Note 1 )

Details of salary paid and any other income and tax deducted.

1 Gross Salary Rs.

(a) Salary as per provisions contained in section 17(1) Rs. 373542.00

(b) Value of perquisites under section 17(2) ( as per Form No. 12BB, whereever applicable Rs.

Profits in lieu of salary under section 17(3) ( as per Form No. 12BB, whereever
(c) Rs.
applicable

(d) Total Rs. 373542.00

2 Less Allowances to the extent exempt under section 10,

House rent allowance Rs. 0.00

Washing allowance Rs. 0.00

Transport allowance Rs. 4800.00 Rs. 4800.00

3 Balance (1-2) Rs. 368742.00

4 Deductions :-

(a)Entertainment allowance Rs.

(b)Tax on Employment Rs. 2400.00

5 Aggregate of 4 (a ) and 4 ( b ) Rs. 2400.00

6 Income chargeble under the head "salaries"(3-5) Rs. 366342.00

7 ADD : Any other income reported by the employee

Income Rs.
0.00

0.00 Rs. 0.00

8 Gross Total Income(6+7) Rs. 366342.00

9 Deduction under Chapter VI-A Rs. Gross Amount Rs. Deductible Amount

(A) Section 80C,80CCC and 80CCD Rs.

(a) Section-80 C Rs.

(i) Rs. 0.00

( ii ) Rs. 0.00

( iii ) Section 80 C Rs. 160438.00 Rs. 100000.00

Note:1 Aggregate amount deductible under Section 80 C shall not be exceed One Lakh rupees.

Note:2 Aggregate amount deductible under the three Section i.e.80 C, 80CCC and Section 80 CCD shall not be exceed One Lakh rupees.

( B ) Other Section ( e.g. 80 E, 80 G etc) under chapter VI-A Gross Amount Qulifting Amount Deductible Amount
(i) Section - 80 D Rs. 0.00 Rs. 0.00 Rs. 0.00

( ii ) Section - 80 DD Rs. 0.00 Rs. 0.00 Rs. 0.00

( iii ) Section - 80 DDB Rs. 0.00 Rs. Err:504 Rs. Err:504

( iv ) Section 80-E Rs. 0.00 Rs. 0.00 Rs. 0.00

(v) Section 80-CCF Rs. 0.00 Rs. 0.00 Rs. 0.00

( vi ) Section-80-G Rs. 0.00 Rs. 0.00 Rs. 0.00

( vii ) Section-80-U Rs. 0.00 Rs. 0.00 Rs. 0.00

"FORM-16"
Page 10 of 31
( viii ) Section 24 ( 2 ) HBA intrest Rs. 8649.00 Rs. 8649.00 Rs. 8649.00

"FORM-16"
Page 11 of 31
 10 Aggregate of deductible amount under chapter VI-A Rs. Err:504

11 Total Income (8-10) Rs. Err:504

Remaining Amount Rounded to Rs.10/- ( Ten) Rs. Err:504

12 Tax on Total Income Rs. Err:504

13 Education cess @ 3 % ( on tax computed at S.No.12) Rs. Err:504

14 Tax Payable ( 12 + 13 ) Rs. Err:504

15 Less Relief Under Section 89 (attach details) Rs. 0.00

16 Tax Payable (14-15) Rs. Err:504

Verification
I C.P.PATEL son / daughter of 0 Working in the

capacity of Administrative Officer (designation ) do hereby certify that a sum of Rs. 0.00
[ Rs NIL ( in words ) ] has been deducted and deposited to the credit of the

Central Government,. I further certify that the information given above is true, complete and correct and is based on the books of account documents ,TDS statement, TDS
deposited and other available records.

Place : VADODRA
Dated: 4/30/2011 Signature of the person responsible for deduction of Tax.

Designation : Administrative Officer (C.P.PATEL )

ANNEXURE - A
Details of Tax Deducted and Deposited in the Central Government Account through book entry.
( The Employer to provide payment wise details of tax Deducted and Deposited withrespect to the employee ).

Book Identification number (BIN)

Sr. Tax Deposited in respect on
No. of the employee (Rs.) DDO Sequence Number in the
Receipt numbers of form no. 24 G Date on which tax Deposited
Book Adjustment Mini Statement

2
3

4
5

7
8

9
10

11
12 0.00

13 0.00

15 1 In the column for TDS, give total amount for TDS,Surcherge ( if applicable) and education cess.

ANNEXURE - B
Details of Tax Deducted and Deposited in the Central Government Account through Challan.
( The Employer to provide payment wise details of tax Deducted and Deposited withrespect to the employee ).

Sr. Tax Deposited in respect on Challan Identification Number (CIN)

No. of the employee (Rs.) BSR Code of the Bank Branch Date on which tax Deposited Challan Serial Number
1

Note : 1 In the column for TDS, give total amount for TDS,Surcherge ( if applicable) and education cess.

"FORM-16"
Page 12 of 31
 INDIAN INCOME TAX RETURN Assessment Year
SAR
FORM

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

First name Middle name Last name PAN

PERSONAL INFORMATION

GRUNDY LEENABEN ALFREDBHAI A C B P G 6 5 0 1 F

Flat/Door/Block No Name Of Premises/Building/Village Date of Birth (DD/MM/YYYY)
W-3 OFFICER COLONY 8/22/1960
Road/Street/Post Office Area/Locality Employer Category (Tick)
B/H CURKIT HOUSE Ö Govt PSU Other
Town/City/District State Pin code Sex (Tick)
VADODARA GUJARAT Male Ö Female
Email Address (STD code)-Phone Number 0256-2438477

Designation of Assessing Officer (Ward/Circle) Return filed under Section - 1 1

FILING STATUS

I.T.O., WARD NO. 4(2) [Please see instruction number-9(i)]

Whether original or Revised return? (Tick) Ö Original Revised
If revised, enter Receipt No and Date of filing original return DD/MM/YYYY
Residential Status (Tick) Ö Resident Non-Resident Resident but Not Ordinarily Resident

1 Income chargeable under the Head ‘Salaries’ ( Salary / Pension ) 1 366342.00

2 Income chargeable under the Head ‘House Property' ( enter -ve sign in case of loss if any ) 2 -8649.00
INCOME & DEDUCTIONS

3 Income chargeable under the Head ‘Other Sources’ ( enter -ve sign in case of loss if any ) 3 0.00
3 Gross Total Income ( 1 + 2 + 3 ) 4 357693.00
5 Deductions under chapter VI A (Section)
a 80CCE 100000.00 e 80E 0.00 i 80GG 0.00
b 80D 0.00 f 80CCF 0.00 j 80GGA 0.00
c 80DD 0.00 g 80G 0.00 k 80GGC 0.00
d 80DDB Err:504 h 80U 0.00 l
6 Deductions ( Total of 5a to 5l ) 6 Err:504
7 Total Income ( 4-6m ) 7 Err:504
8 Tax Payable on Total Income 8 Err:504
TAX COMPUTATION

9 Secondary and Higher education cess on ( 8 ) 9 Err:504

10 Total Tax, Surcharge and Education Cess Payable ( 8 + 9 ) 10 Err:504
11 Relief under Section 89 11 0.00
12 Relief under Section 90/91 12 0.00
13 Balance Tax Payable (10-11-12) 13 Err:504
14 Interest Payable u / s 234A / 234B / 234 C 14 0.00
15 Total Tax and Interest Payable (13+14) 15 Err:504
Do not write or stamp in this area Seal and Signature of receiving official
For Office Use Only

Receiiptt No
Date
 16 Taxes Paid
a Advance Tax (from item 25) 16a 0.00
TAXES PAID

b TDS (column 7 of item 23 +column 7 of item 24) 16b 0.00

c Self Assessment Tax (from item 25) 16c
17 Total Taxes Paid (16a+16b+16c) 17 0.00
18 Tax Payable (15-17) (Enter if 15 is greater than 17, else leave blank) 16 Err:504
19 Refund (17-16) (enter if 17 is greater than 16, also give Bank Account details below) 17 Err:504
REFUND

20 Enter your bank account number (mandatory in case of refund) 6 2 4 5 0 1 0 4 1 4 1 3

21 Do you want your refund by Ö cheque, or deposited directly into your bank account? (tick as applicable)
22 Give additional details of your bank account
MICR Code Type of Account (tick as applicable) Ö Savings Current

23 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]

Sr Tax Deduction Account Number (TAN) of the Name and address of the Income Tax payable
Deduction under Total tax Tax payable
chargeable under ( Incl. education
No. Employer Employer Chapter VI-A deducted /refundable
TDS ON SALARY

the head Salaries cess)

(1) (2) (3) (4) (5) (6) (7) (8)

i DY.DIRECTOR, 913, E-
357693 Err:504 Err:504 0 Err:504
A A A L D 0 2 5 1 A BLOCK, VADODRA
ii
, , 0

24 Details of Tax Deducted at Source other than salary

Date of Amount out
Sr Tax Deduction Account Number (TAN) of the Name and address of the Amount paid / Credit Payment / Total tax deducted of (6) claimed
No. Deductor Deductor
Credit for this year
1 (2) (3) (4) (5) (6) (7)
TDS ON INTEREST

i
0

ii
0

iii
0

Note Enter the totals of column (7) of 23 and column (7) of 24 in Sl No. 17 of TAXES PAID

25 Details of Advance Tax and Self Assessment Tax Payments

Sl Date of Deposit Serial Number of
Name of Bank & Branch BSR Code Amount (Rs)
TAX PAYMENTS

No. (DD/MM/YYYY) Challan

i
ii
iii
iv
v
Note Enter the totals of Advance tax and Self Assessment tax in Sl No. 17 a and 15c of TAXES PAID

26 Other Information (transactions reported through Annual Information Return) (Please see instruction number-9(ii) for code)
Sr. Code Amount (Rs) Sr. Code Amount (Rs) Sr. Code Amount (Rs)
A 001 D 004 G 007
B 002 E 005 H 008
C 003 F 006

27 Exempt income any for reporting purposes ( from Dividend, Capital gains etc) 27

VERIFICATION
solemniy declare that to the best of my knowledge and belief, the /information
I, GRUNDY LEENABEN ALFREDBHAI son daughter ofgiven in the return
GRUNDY
thereto isALFREDBHAI THOMASand that the
correct and complete
amount of total income and other particulars shown therein are truly stated and are in accordance with the provisions of the Income-tax
Act,2011-2012
1961, in respect of income chargeable to Income-tax for the previous year relevant to the Assessment Year

Place VADODARA Date Sign here -->

28 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

29 If TRP is entitled for any reimbursement from the Government, amount thereof (to be filled by TRP) 29
 Government of India

INCOME TAX - DEPARTMENT

ACKNOWLEDGEMENT
Received with thanks fro GRUNDY LEENABEN ALFREDBHAI a return of income
and / or return of fridge benefits in Form No. SARAL - II for the assessment year 2011-2012 having the following particulars
PERSONAL INFORMATION

Name PAN
GRUNDY LEENABEN ALFREDBHAI A C B P G 6 5 0 1 F
Flat/Door/Block No Name Of Premises/Building/Village
W-3 OFFICER COLONY
Road/Street/Post Office Area/Locality
B/H CURKIT HOUSE
Town/City/District State
VADODARA GUJARAT

1 Gross Total Income 1 357693.00

2 Deductions under chapter VI A (Section) 2 Err:504
COMPUTATION OF INCOME AND TAX

3 Total Income 3 Err:504

4 Net tax payable 6 Err:504
5 Interest payable 7
6 Total tax and Interest payable 6 Err:504
THEREON

7 Taxes Paid
a Advance Tax 7a 0.00
b TDS 7b 0.00
c TCS 7c 0.00
d Self Assessment Tax 7d
d Total Taxex Paid (7a + 7b + 7c + 7d ) 7e 0.00
8 Tax Payable ( 6 - 7d ) 8 Err:504
9 Refund ( 7e - 6 ) 9 Err:504

10 Value of Fridge benefits 10

FRINGE BENEFITS AND

11 Total Fridge benefit tax liability 11

COMPUTATION OF

12 Total interest payable 12

TAX THEREON

13 Total tax and Interest payable 13

14 Taxes Paid
a Advance Tax 14a
b Self Assessment Tax 14b
c Total Taxes Paid (14a+14b) 14c
15 Tax Payable (13-14c) 15
16 Refund (14c-13) 16

Receiiptt No Seal and Signature of receiving official

Date
 INDIAN INCOME TAX RETURN Assessment Year
FORM ITR-1 [For Individuals having Income from Salary / Pension / Family Pension & Interest]
(Please see Rule 12 of the Income-tax Rules,1962) 2 0 1 1 - 1 2
(Also see attached instructions)

First name Middle name Last name PAN

PERSONAL INFORMATION

GRUNDY LEENABEN ALFREDBHAI A C B P G 6 5 0 1 F

Flat/Door/Block No Name Of Premises/Building/Village Date of Birth (DD/MM/YYYY)
W-3 OFFICER COLONY 8/22/1960
Road/Street/Post Office Area/Locality Employer Category (Tick)
B/H CURKIT HOUSE Ö Govt PSU Other
Town/City/District State Pin code Sex (Tick)
VADODARA GUJARAT Male Ö Female
Email Address (STD code)-Phone Number 0256-2438477

Designation of Assessing Officer (Ward/Circle) Return filed under Section - 1 1

FILING STATUS

I.T.O., WARD NO. 4(2) [Please see instruction number-9(i)]

Whether original or Revised return? (Tick) Ö Original Revised

If revised, enter Receipt No and Date of filing

original return (DD/MM/YYYY)

Residential Status (Tick) Ö Resident Non-Resident Resident but Not Ordinarily Resident

1 Income chargeable under the Head ‘Salaries’ ( Salary / Pension ) 1 366342.00

2 Income chargeable under the Head ‘Other Sources’
a Family Pension 2a
b Interest 2b 0.00
c Total ( 2a + 2b ) 2c 0.00
INCOME & DEDUCTIONS

3 Gross Total Income ( 1 + 2c ) 3 366342.00

4 Deductions under chapter VI A (Section)
a 80C 100000.00 e 80DD 0.00 i 80GG 0.00
b 80CCC 0.00 f 80DDB Err:504 j 80GGA 0.00
c 80CCD 0.00 g 80E 0.00 k 80GGC 0.00
d 80D 0.00 h 80G 0.00 l 80U 0.00
m Deductions ( Total of a to l ) 4m Err:504
5 Total Income ( 3-4m ) 5 Err:504
6 Net Agricultural Income (Enter only if greater than Rs 5,000) 6
7 ‘Aggregate Income’ (5+6) 7 Err:504
8 a Tax Payable on ‘Aggregate Income’ 8a Err:504
b Rebate in respect of Net Agricultural income 8b 0.00
9 a Tax Payable on Total Income ( 8a-8b ) 9a Err:504
TAX COMPUTATION

b Surcharge on 9a 9b 0.00
Education Cess,including secondary and higher education cess on
c
( 9a+9b )
9c Err:504

d Total Tax, Surcharge and Education Cess Payable ( 9a + 9b + 9c ) 9d Err:504

10 Relief under Section 89 10 0.00
11 Relief under Section 90/91 11 0.00
12 Balance Tax Payable (9d-10-11) 12 Err:504
Do not write or stamp in this area (Space for bar code) 13 a Interest Payable U/s 234A 13a
b Interest Payable U/s 234B 13b
c Interest Payable U/s 234C 13c
Total Interest Payable
d
(13a+13b+13c)
13d 0.00
Total Tax and Interest Payable
14
(12+13d)
14 Err:504
For Office Use Only Seal and Signature of receiving official

Receiiptt No

Date
 15 Taxes Paid
a Advance Tax (from item 23) 15a 0.00
TAXES PAID
b TDS (column 7 of item 21 +column 7 of item 22) 15b 0.00
c Self Assessment Tax (from item 23) 15c
d Total Taxes Paid (15a+15b+15c) 15d 0.00
16 Tax Payable (14-15d) (Enter if 14 is greater than 15d, else leave blank) 16 Err:504
17 Refund (15d-14) (enter if 15d is greater than 14, also give Bank Account details below) 17 Err:504
REFUND

18 Enter your bank account number (mandatory in case of refund) 6 2 4 5 0 1 0 4 1 4 1 3

19 Do you want your refund by Ö cheque, or deposited directly into your bank account? (tick as applicable)
20 In case of direct deposit to your bank account give additional details
MICR Code Type of Account (tick as applicable) Ö Savings Current

21 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]
Tax
Sr Tax Deduction Account Number (TAN) of the Name and address of the Income Deduction
payable( Incl. Total tax Tax payable
chargeable under under Chapter
No. Employer Employer surch. and edu. deposited /refundable
the head Salaries VI-A
cess)
TDS ON SALARY

(1) (2) (3) (4) (5) (6) (7) (8)

i DY.DIRECTOR, 913, E-
366342 Err:504 Err:504 0 Err:504
BLOCK, VADODRA
A A A L D 0 2 5 1 A
ii
, , 0

22 Details of Tax Deducted at Source on Interest [As per Form 16 A issued by Deductor(s)]
Amount out
Date of
Sr Tax Deduction Account Number (TAN) of the Name and address of the of (6)
Amount paid / Credit Payment / Total tax deposited
No. Deductor Deductor claimed for
Credit
this year
TDS ON INTEREST

1 (2) (3) (4) (5) (6) (7)

i
0

ii
0

iii
0

Note Enter the totals of column (7) of 21 and column (7) of 22 in Sl No. 15b of TAXES PAID

23 Details of Advance Tax and Self Assessment Tax Payments

Sl Date of Deposit Serial Number of
Name of Bank & Branch BSR Code Amount (Rs)
TAX PAYMENTS

No. (DD/MM/YYYY) Challan

i
ii
iii
iv
v
Note Enter the totals of Advance tax and Self Assessment tax in Sl No. 15 a and 15c of TAXES PAID

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

25 Tax-exempt interest income (for reporting purposes only) 25

VERIFICATION
I, GRUNDY LEENABEN ALFREDBHAI son / daughter of GRUNDY ALFREDBHAI THOMAS

solemniy 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 2011-2012

Place VADODARA Date Sign here -->

26 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
If TRP is entitled for any reimbursement from the Government, amount thereof (to be filled by TRP) 28
 Government of India

INCOME TAX - DEPARTMENT

ACKNOWLEDGEMENT
Received with thanks f GRUNDY LEENABEN ALFREDBHAI a return of income
and / or return of fridge benefits in Form No. ITR - 1 for the assessment year 2011-2012 having the following particulars

Name PAN

GRUNDY LEENABEN ALFREDBHAI A C B P G 6 5 0 1 F

PERSONAL INFORMATION

Flat/Door/Block No Name Of Premises/Building/Village

W-3 OFFICER COLONY

Road/Street/Post Office Area/Locality

B/H CURKIT HOUSE

Town/City/District State

VADODARA GUJARAT

1 Gross Total Income 1 366342.00

2 Deductions under chapter VI A (Section) 2 Err:504
COMPUTATION OF INCOME AND TAX THEREON

3 Total Income 3 Err:504

4 Net tax payable 6 Err:504
5 Interest payable 7 0.00
6 Total tax and Interest payable 6 Err:504
7 Taxes Paid

a Advance Tax 7a 0.00

b TDS 7b 0.00
c TCS 7c 0.00
d Self Assessment Tax 7d

d Total Taxex Paid (7a + 7b + 7c + 7d ) 7e 0.00

8 Tax Payable ( 6 - 7d ) 8 Err:504
9 Refund ( 7e - 6 ) 9 Err:504

10 Value of Fridge benefits 10

COMPUTATION OF FRINGE BENEFITS

11 Total Fridge benefit tax liability 11

12 Total interest payable 12

AND TAX THEREON

13 Total tax and Interest payable 13

14 Taxes Paid

a Advance Tax 14a

b Self Assessment Tax 14b

c Total Taxes Paid (14a+14b) 14c

15 Tax Payable (13-14c) 15

16 Refund (14c-13) 16

Receiiptt No Seal and Signature of receiving official

Date
 INDIAN INCOME TAX RETURN Assessment Year
FORM ITR-2 [For Individuals and HUFs not having Income from Bussiness or Profession]
(Please see Rule 12 of the Income-tax Rules,1962) 2 0 1 1 - 1 2
(Also see attached instructions)

Part A Gen GENERAL

First name Middle name Last name PAN

GRUNDY LEENABEN ALFREDBHAI A C B P G 6 5 0 1 F

PERSONAL INFORMATION

Flat/Door/Block No Name Of Premises/Building/Village Status ( Tick )

W-3 OFFICER COLONY Ö Individual HUF
Date of Birth (DD/MM/YYYY)
Road/Street/Post Office Area/Locality ( in case of individual )

B/H CURKIT HOUSE 8/22/1960

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

VADODARA GUJARAT Male Ö Female

Employer Category ( if in
Email Address (STD code)-Phone Number
empoyment ) (Tick)
0256-2438477 Ö Govt PSU Other

Designation of Assessing Officer (Ward/Circle) Return filed under Section - 1 1

I.T.O., WARD NO. 4(2) [Please see instruction number-9(i)]

Whether original or Revised return? (Tick) Ö Original Revised

If revised, enter Receipt No and Date of filing

FILING STATUS

original return (DD/MM/YYYY)

Residential Status (Tick) Ö Resident Non-Resident Resident but Not Ordinarily Resident

Whether this return is being filed by a representative assesseem ? ( tick ) Ö Yes Ö No

If yes, please furnish following information

( a ) Name of representative
( b ) Address of representative

( c ) Permanent Account Number ( PAN ) of the representative

Part B
Part B - TI Computation of total income
1 Salaries ( 6 of Schedule S ) 1 366342.00
2 Income from house property ( 3c of scedule HP ) ( enter nil if loss ) 2 0.00
3 Capital gains
TOTAL INCOME

a Short term

I Short - term ( u/s 111 A ( A5 of schedule CG ) 3ai 0.00

II Short - term ( others ) ( A6 of schedule CG ) 3aii 0.00
III Total Short - term ( 3ai + 3aii ) (A4 of schedule CG 3aiii 0.00
b Long term ( B5 of schedule CG ) ( enter nil if loss ) 3b 0.00
c Total capital gains ( 3aiii + 3b ) 3c 0.00
Do not write or stamp in this area (Space for bar code) For Office Use Only

Receiiptt No

Date

Seal and Signature of receiving official

Page 21
 4 Income from other sources
a from sources other than from owning race horses ( 3 of Schedule OS) 4a 0.00
b from owning race horses ( 4c of Schedule OS ) ( enter nil if loss) 4b 0.00
c total ( a + b ) ( enter nil if 4c is a loss) 4c 0.00
5 Total ( 1 + 2 + 3c + 4c ) 5 366342.00
6 Losses of current year set off against 5 ( total of 2vi and 3 vi of schedule CYLA ) 6 -8649.00
7 Balance after set off current year losses ( 5 - 6 ) ( also total of column of 4 of schedule CYLA ) 7 357693.00
8 Brought forward losses set off against 7 ( 2vi of shedule BFLA ) 8 0.00
9 Gross Total income ( 7 - 8 ) ( also 3vii of shedule BFLA ) 9 357693.00
10 Deduction under chapter VI - A ( n of shedule VIA ) 10 Err:504
11 Total income ( 9 - 10 ) 11 Err:504
12 Net agricultural income / any other income for rate purpose ( 4 of schedule El ) 12 0.00
13 Aggregate income ( 11 +- 12 ) 13 Err:504
14 Losses of current year to be carried forward ( total of row xi of schedule CFL ) 14 0.00
Part B - TTI Computation of tax liability on total income
1 Tax Payable on Total Income
a Tax at normal rates 1a Err:504
b Tax at special rates ( 11 of schedule SI ) 1b
c Tax Payable on Total Income ( 1a + 1b ) 1c Err:504
2 Surcharge on 1c 2 0.00
COMPUTATION OF TAX LIABILITY

3 Education Cess, including secondary and higher education cess on ( 1c + 2 ) 3 Err:504

4 Gross tax liability ( 1c + 2 + 3 ) 4 Err:504
5 Tax relief
a Section 89 5a 0.00
b Section 90 5b
c Section 91 5c
d Total ( 5a + 5b + 5c ) 5d 0.00
6 Net tax liability ( 4 - 5d ) 6 Err:504
7 Interest payable
a For default in furnishing the return ( section 234A ) 7a
b For default in payment of advance tax ( section 234B ) 7b
c For deferment of advance tax ( section 234AC ) 7c
d Total Interest Payable ( 7a + 7b + 7c ) 7d 0.00
8 Aggregate liability ( 6 + 7d ) 8 Err:504
9 Taxes Paid
a Advance Tax (from schedule - IT ) 9a 0.00
TAXES PAID

TDS (total of column 7 of schedule - TDS1 and column

b
7 of schedule - TDS-2)
9b 0.00
c Self Assessment Tax (from schedule-IT ) 9c
d Total Taxes Paid ( 9a+9b+9c) 9d 0.00
10 Amount Payable (Enter if 8 is greater than 9d, else enter 0 ) 10 Err:504
11 Refund ( if 9d is greater than 8, also give Bank Account details below) 11 Err:504
12 Enter your bank account number (mandatory in case of refund) 6 2 4 5 0 1 0 4 1 4 1 3
REFUND

13 Do you want your refund by Ö cheque, or deposited directly into your bank account? (tick as applicable)
14 In case of direct deposit to your bank account give additional details
MICR Code Type of Account (tick as applicable) Ö Savings Current

VERIFICATION
I, GRUNDY LEENABEN ALFREDBHAI son / daughter of GRUNDY ALFREDBHAI THOMAS

solemniy declare that to the best of my knowledge and belief, the information given in the return and shedules 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
provision of the Income-tax Act, 1961, in respect of income chargeble to Income-tax for the previous year relevent to the
Assessment Year 2011-2012

Place Date Sign here -->

Page 22
15 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

If TRP is entitled for any reimbursement from the Government, amount thereof 16

Schedule - S Details of income from salary

Name of Employer PAN of employer (optional )
DY.DIRECTOR A A A L D 0 2 5 1 A
Address of employer Town / City State PIN code
913, E-BLOCK VADODRA GUJARAT
SALARIES

1 Salary ( Excluding all allowanse, prequisites & profit in lieu of salary ) 1 366342.00
2 Allowances exempt under section 10 2 7200.00
3 Allowances not exempt 3
4 Value of perquisites 4
5 Profit in lieu of salary 5
6 Income chargeble under the Head "Salaries" ( 1+3+4+5 ) 6 366342.00
Schedule - HP Details of income from House Property ( Please refer to instructions. )
Address of property 1 Town / City State PIN code
1
W-3, OFFICER COLONY, B/H CURKIT HOUSE VADODARA GUJARAT

Tick Ö if let out Name of Tenant PAN of Tenant (optional )

Annual letable value / rent received or receivable ( Higher if let out for whole of the year,
a 1a 0.00
lower if let out for part of the year. )
b The amount of rent which cannot be realized 1b
c Tax paid to local authorities. 1c
d Total ( 1b + 1c ) 1d 0.00
e Balance ( 1a - 1d ) 1e 0.00
f 30 % of 1e 1f 0.00
g Interest payable on borrowed capital 1g 8649.00
h Total ( 1f + 1g ) 1h 8649.00
HPUSE PROPERTY

i Income from house property 1 ( 1e - 1h ) 1i -8649.00

Address of property 2 Town / City State PIN code
2

Tick Ö if let out Name of Tenant PAN of Tenant (optional )

Annual letable value / rent received or receivable ( Higher if let out for whole of the year,
a 2a
lower if let out for part of the year. )
b The amount of rent which cannot be realized 2b
c Tax paid to local authorities. 2c
d Total ( 2b + 2c ) 2d
e Balance ( 2a - 2d ) 2e
f 30 % of 2e 2f
g Interest payable on borrowed capital 2g
h Total ( 2f + 2g ) 2h
i Income from house property 2 ( 2e - 2h ) 2i
3 Income under the head " Income from house property "
a Rent of earlier years realized under section 25 A / AA 3a
b Arrears of rent received during the year under section 25 B after deducting 30 % 3b
c Total ( 3a + 3b + 1i + 2i ) 3c -8649.00
NOTE > Please include the income of the specified person referred to in Schedule SPI while computing the income under this head.

Schedule - CG Capital Gains

A Short term capital gains
1 From assets in case of non-resident to which first proviso to section 48 applicable 1
CAPITAL GAINS

2 From other assets

a Full value of consideration 2a
b Deduction under section 48
i Cost of acquisition bi
ii Cost of Improvement bii
iii Expenditure of transfer biii

Page 23
 iv Total ( i +ii + iii ) biv
c Balance ( 2a - biv ) 2c
Loss if any, to be ignored under section 94(7) or
CAPITAL GAINS
d 2d
94(8) ( enter positive values only. )
e Exemption under section 54B/54D 2e
f Short term capital gain ( 2c - 2d - 2e ) 2f
3 Amount deemed to be short term capital gains under section 54B/54D/54EC/54ED/54G/54GA A3
4 Total short term capital gain ( 1 + 2f + A3 ) A4
5 Short term capital gain under section 111A included in 4 A5
6 Short term capital gain other than referred to in secion 111A (A4 - A5 ) A6
B Long term capital gains
1 Assets in case of non-resident to which first proviso to section 48 applicable 1
2 Other assets where proviso to section 112 (1) not applicable
a Full value consideration 2a
b Deduction under section 48
i Cost of acquisition after indexation bi
ii Cost of Improvement after indexation bii
iii Expenditure on transfer biii
iv Total ( bi +bii + biii ) biv
c Balance ( 2a - biv ) 2c
Exemption under sections
d 54/54B/54D/54EC/54F/54G/54GA 2d
e Net balance ( 2c - 2d ) 2e
3 Other assets where proviso to section 112 (1) is applicable
CAPITAL GAINS

a Full value consideration 3a

b Deduction under section 48
i Cost of acquisition without indexation bi
ii Cost of Improvement without indexation bii
iii Expenditure on transfer biii
iv Total ( bi +bii + biii ) biv
c Balance ( 3a - biv ) 3c
d Exemption under sections 54/54B/54D/54EC/54F 3d
e Net balance ( 3c - 3d ) 3e
4 Amount deemed to be long term capital gains under section 54/54B/54D/54EC/54ED/54F B4
5 Total long term capital gain 1 + 2e [ (enter 2e as nil if loss) + 3e (enter 3e as nil if loss)+ 4 )] B5
C Income chargeable under the head " CAPITAL GAINS " ( A4 + B5 ) (enter B5 as nil, if loss) C
D Information about actual / receipt of capital gain
Upto 15/9 16/9 to 15/12 16/12 to 15/3 16/3 to 31/3
Date
(i) ( ii ) ( iii ) ( iv )
1 Long - term
2 Short - term
NOTE > Please include the income of the specified persons referred to in Schedule SPI while computing the income under this head.

Schedule - OS Income from other sources

1 Income
a Dividends, Gross 1a 0.00
b Interest Gross 1b 0.00
c Rental income from machinery, plants, buildings, 1c
d Other, Gross ( excluding income from owning race horses ) 1d 0.00
e Total ( 1a + 1b + 1c + 1d ) 1e 0.00
OTHER SOURCES

f Deduction under section 57 :-

i Expenses fi
ii Depreciation fii
iii Total fiii 0.00
g Balance ( 1e - fiii ) 1g 0.00
2 Winning from lotteries, crossword puzzles, races, etc. 2
3 Income from other sources ( other than owning race horses ) ( 1g + 2 ) (enter 1g as nil, if loss) 3 0.00
4 Income from owning and maintaining race horses.
a Receipts 4a
b Deduction under section 57 in relation to ( 4 ) :- 4b
c Balance ( 4a - 4b ) 4c 0
Income chargeable under the head " Income from other sources" ( 3 + 4c ) (enter 4c as nil if loss
5 5 0.00
and take 4c loss figure to schedule CFL)
NOTE > Please include the income of the specified persons referred to in Schedule SPI while computing the income under this head.

Page 24
Schedule - CYLA Details of Income after Set off of current year losses.
Sr.No. Head / Sources of Income Income of current year ( Fill House property loss of the Other sources loss ( other than Current year's Income
this column only if income is current year set off loss from race horses ) of the remaining after set off
zero or positive ) current year set off
CURRENT YEAR LOSS ADJUSTMENT

Total loss ( 3c of Schedule - Total loss ( 3 of Schedule -

HP ) OS )

1 2 3 4=1-2-3
Lose to be adjusted

i Salaries 366342.00 -8649.00 357693.00

ii House Property

iii Short term capital gain

iv Long term capital gain

Other sources ( including

v profit from owning race
horses )

vi Total loss set off -8649.00

vii Loss remaining after set-off out of 2 & 3

BROUGHT FORWARD LOSS ADJUSTMENT

Schedule - BFLA Details of Income after Set off of Brought Forward losses of earlier years.
Sr.No. Head / Sources of Income Income after set off, if any, of current Brought forward loss set off Current year's Income remaining after set
year's losses as per 4 of schedule CYLA off

1 2 3
i Salaries
ii House Property
iii Short term capital gain
iv Long term capital gain
Other sources ( including
v profit from owning race
horses )

vi Total of brought forward loss set off

vii Current year's income remaining after set-off Total ( i3 + ii3 + iii3 + iv3 + v3 )

Schedule - CFL Details of Losses to be carried Forward to future years.

Sr.No. Assessment year Data of filing House property loss Short term capital loss Long term Other sources loss ( from owning race
(DD/MM/YYYY) capital loss horses )
i 2000-01
CARRY FORWARD OF LOSS

ii 2001-02
iii 2002-03
iv 2003-04
v 2004-05
vi 2005-06
vii 2006-07
viii 2007-08
ix Total of earliar year losses
x Adjustment of above losses in
Schedule BFLA
xi 2008-09 ( Current year losses )
Total loss Carried Foraward to
xii future years

Schedule - VIA Deductions under chapter VI A (Section)

a 80C 100000.00 h 80G 0.00
b 80CCC 0.00 i 80GG
TOTAL DEDUCTIONS

c 80CCD 0.00 j 80GGA

d 80D 0.00 k 80GGC

e 80DD 0.00 l 80RRB

f 80DDB Err:504 m 80U 0.00

g 80E 0.00
n Total deductions ( total a toi m ) n Err:504

Page 25
 Income of specified persons(spouse, minor child etc) includable of the assessee ( income
Schedule - SPI of the minor child to be included after Rs. 1,500 per child)
Sr.No. Name of person PAN of person (optional) Relationship Nature of Income Amount(Rs.)
1
2
3

Income chargeble to Income tax at special rates [ Please see instruction No.9(iii) for
Schedule - SI section code and rate of tax]
Sr. Section Special rate Income Tax thereon Sr. Special rate Income Tax thereon
No. code Ö (%) i ii No.
Section code Ö
(%) i ii
SPECIAL RATE

1 6
2 7
3 8
4 9
5 10
11 Total ( 1ii to 10 ii )

Schedule - EI Details of Exempt Income ( Income not to be included in Total Income )

1 Interest income 1
EXEMPT INCOME

2 Dividend income 2
3 Long term capital gains from transaction on which Securities Transaction Tax is paid 3
4 Neat Agriculture income / any other income for rate purpose 4
5 Others, including exempt income of minor children 5
6 Total ( 1 + 2 + 3 + 4 + 5 ) 6
Other Information (transactions reported through Annual Information Return)
Schedule - AIR [ Please see instruction No.9(ii) for code ]
SI Code of transaction Ö Amount ( Rs. ) SI Code of transaction Ö Amount ( Rs. )
1 001 5 005
2 002 6 006
3 003 7 007
4 004 8 008

Schedule - IT Details of Advance Tax and Self Assessment Tax Payments of Income - tax.
Sl Date of Deposit Serial Number of
Name of Bank & Branch BSR Code Amount (Rs)
No. (DD/MM/YYYY) Challan
TAX PAYMENTS

i
ii
iii
iv
v
NOTE > Enter the totals of Advance tax and Self Assessment tax in Sl No. 9a and 9c of Part-B TTI.

Schedule - TDS1 Details of Tax Deducted at Source from Salary [As per Form 16 issued by Employer(s)]
Deduction Tax payable( Total
Income Tax
Sr Tax Deduction Account Number (TAN) of the Name and address of the chargeable under Incl. surch. tax
under payable
No. Employer Employer the head Salaries Chapter VI- and edu. deposite
/refundable
A cess) d
TDS ON SALARY

(1) (2) (3) (4) (5) (6) (7) (8)

i DY.DIRECTOR, 913, E-
357693 Err:504 Err:504 0 Err:504
BLOCK, VADODRA
A A A L D 0 2 5 1 A
ii
, , 0 0 0

Schedule - TDS2 Details of Tax Deducted at Source on Income [As per Form 16 A issued by Deductor(s)]

Amount out
Date of
TDS ON OTHER INCOME

Sr Tax Deduction Account Number (TAN) of the Name and address of the Total tax of (6)
Amount paid / Credit Payment /
No. Deductor Deductor deposited claimed for
Credit
this year
(1) (2) (3) (4) (5) (6) (7)
i
0

ii
0

Page 26
 TDS ON
0

NOTE > Enter the total of column (7) of Schedule TDS-1 and column (7) of Schedule-TDS-2 in 9 (b) of Part B - TTI.

Government of India

INCOME TAX - DEPARTMENT

ACKNOWLEDGEMENT
Received with thanks f GRUNDY LEENABEN ALFREDBHAI a return of income
and / or return of fridge benefits in Form ITR - 2 for the assessment year 2011-2012 having the following particulars

Name PAN

GRUNDY LEENABEN ALFREDBHAI

PERSONAL INFORMATION

A C B P G 6 5 0 1 F
Flat/Door/Block No Name Of Premises/Building/Village

W-3 OFFICER COLONY

Road/Street/Post Office Area/Locality

B/H CURKIT HOUSE

Town/City/District State

VADODARA GUJARAT

1 Gross Total Income 1 366342.00

2 Deductions under chapter VI A (Section) 2 Err:504
COMPUTATION OF INCOME AND TAX THEREON

3 Total Income 3 Err:504

4 Net tax payable 6 Err:504
5 Interest payable 7 0.00
6 Total tax and Interest payable 6 Err:504
7 Taxes Paid

a Advance Tax 7a 0.00

b TDS 7b 0.00
c TCS 7c

d Self Assessment Tax 7d

d Total Taxex Paid (7a + 7b + 7c + 7d ) 7e 0.00

8 Tax Payable ( 6 - 7d ) 8 Err:504
9 Refund ( 7e - 6 ) 9 Err:504

10 Value of Fridge benefits 10

COMPUTATION OF FRINGE BENEFITS

11 Total Fridge benefit tax liability 11

12 Total interest payable 12

AND TAX THEREON

13 Total tax and Interest payable 13

14 Taxes Paid

a Advance Tax 14a

b Self Assessment Tax 14b

c Total Taxes Paid (14a+14b) 14c

15 Tax Payable (13-14c) 15

16 Refund (14c-13) 16

Receiiptt No Seal and Signature of receiving official

Page 27
Date

Page 28
;DH]TL ov TFP !5q_*q!)() GF ZMH BZLN SZ[, ~FP !____qvGL lS\DTGF V[GPV[;P;LP G]\ K99
JQF"G]\ jIFH U6J]\ K[P TM VF TFZLB TFP_(q_5q!)() YL TFP#!q!Zq!))( JrR[ VFJ[ K[PT[GL
;FD[ SM0 ccV[cc VF5[, K[P TM 5L/F S,ZGF ;[,DF\ ccV[cc ;FY[ ccKcc ,BMPU|[ S,ZGF ;[,DF\ ~F
!____qv ,BMP 5ZL6FD[ HF\A,L S,ZGF ;[,DF\ V[GPV[;P;LP H[ T[ JQF"GL jIFHGL ZSD
~FPZZ$_qv D/X[P VF ZLT[ H]NF H]NF S], !_ V[GPV[;P;LPGF jIFHGL U6TZL V[SL
;FY[ SZLG[ jIFHGL S], ZSD GLR[ VF5[, 5M58L S,ZGF ;[,DF\ D/X[P
08-5-1989 TO 31-12-1998 A D1 5000.00
01-01-1999 TO 14-01-2000 B D2 5000.00
15-01-2000 TO 28-02-2001 C D3 5000.00
01-03-2001 TO 28-02-2002 D D4 5000.00
01-03-2002 TO 28-02-2003 E D5 5000.00
01-03-2003 TO ONWARDS F D6 5000.00
B4 0.00
C3 0.00
D2 0.00
E1 0.00
 lS\DTGF V[GPV[;P;LP G]\ K99F
!q!Zq!))( JrR[ VFJ[ K[PT[GL
ccKcc ,BMPU|[ S,ZGF ;[,DF\ ~FP
T[ JQF"GL jIFHGL ZSD
jIFHGL U6TZL V[SL
D/X[P
486.00 4.86
533.50 5.335
585.50 5.855
642.50 6.425
705.00 7.05
773.50 7.735
0.00
0.00
0.00
0.00

3726.00

A1 124.00
A2 139.00
A3 156.00
A4 175.00
A5 197.00
A6 224.00
B1 118.30
B2 132.30
B3 148.00
B4 165.40
B5 185.10
B6 206.90
C1 113.00
C2 125.80
C3 140.00
C4 155.80
C5 173.50
C6 193.10
D1 97.20
D2 106.70
D3 117.10
D4 128.50
D5 141.00
D6 154.70
E1 92.00
E2 100.50
E3 109.70
E4 119.80
E5 130.90
E6 142.90
F1 81.60
F2 88.30
F3 95.50
F4 103.30
F5 111.70
F6 120.80