National Board of Revenue IT-11GA2016

www.nbr.gov.bd RETURN OF INCOME

For an Individual Assessee
The following schedules shall be the integral part of this return and must be annexed to
return in the following cases:
Schedule 24A if you have income from Salaries.
Photo
Schedule 24B if you have income from house property
Schedule 24C if you have income from business or profession.
Schedule 24D if you claim tax rebate
PART 1
Basic information
01 Assessment Year 02 Return submitted under section 82BB?
(tick one)
Yes No

03 Name of the Assessee 04 Gender (tick one)

2 0 1 9 2 0 M F
05 Twelve-digit TIN 06 Old TIN

07 Circle 08 Zone

09 Resident Status (tick one) Resident Non-resident

10 Tick on the box(es) below if you are:

10A A gazetted war-wounded 10B A person with Diability

freedom fighter
10C Aged 65 years or more 10D A parent/legal guardian of person
with disability

11 Date of birth (DD-MM-YYYY) Income Year

to
13 If employed, employer's name

14 Spouse Name 15 Spouse TIN (if any)

16 Father's Name 17 Mother's Name

18 Present Address 19 Permanent Address

20 Contact Telephone 21 E-mail

22 National Identification Number 23 Business Identification Number(s)

 PART II
Particulars of Income and Tax
TIN:

Particulars of Total Income Amount $

24 Salaries (annex Schedule 24A) S.21

25 Interest on securities S.22

26 Income from house property (annex Schedule 24B) S.24

27 Agricultural income S.26

28 Income from business or profession (annex Schedule 24C) S.28

29 Capital gains S.31

30 Income from other sources S.33

31 Share of income from firm or AOP

32 Income of minor or spouse under section 43(4) S.43

33 Foreign income

34 Total income (aggregate of 24 to 33)

Tax Computation and Payment Amount $

35 Gross tax before tax rebate

36 Tax rebate (annex Schedule 24D)

37 Net tax after tax rebate

38 Minimum tax

39 Net wealth surcharge

40 Interest or any other amount under the Ordinance (if any)

41 Total amount payable

42 Tax deducted or collected at source (attach proof)

43 Advance tax paid (attach proof)

44 Adjustment of tax refund [mention assessment year(s) of refund]

45 Amount paid with return (attach proof)

46 Total amount paid and adjusted (42+43+44+45)

47 Deficit or excess (refundable) (41-46)

48 Tax exempted income

 PART III
Instruction, Enclosures and Verification

TIN TIN:

49 Instruction s
1. Statement of assets, liabilities and expenses (IT-10B2016) and statement of life style expense
(IT-10BB2016) must be furnished with the return unless you are exemted from furnishing
such statement(s) under section 80.
2. Proof of payments of tax, including advance tax and withholding tax and the proof of
investment for tax rebate must be provided along with return.
3. Attach account statemet and other documents where applicable.
2 0
50 If you are a parent of a person with disability,has youre spouse Yes No.
availed the extended tax exemtion threshold? (tick one)

51 Are you required to submit a statement of assets, liabilities and Yes No.
expenses (IT-10B2016)2 under
0 section 80(1)? (tick one)
52 Schedules annexed
24A 24B 24C 24D
(tick all that are applicabel)
53 Schedules annexed
IT-10B2016 IT-10BB2016
(tick all that are applicabel)
54 Other statements, documents, etc. attached (list all)

2 0

Verification and signature

55 Verification
I solemnly declare that to the best of my knowledge and belief the information given in this return
and statement and documents annexed or attached herewith are correct and complete.

Name Signature

Date of Signature (DD-MM-YYYY) Place of Signature

For official use only

Return Submission Information
Date of Signature (DD-MM-YYYY) Place of Signature
 National Board of Revenue IT-10B2016
www.nbr.gov.bd
STATEMENT OF ASSETS, LIABILITIES AND EXPENSES
under section 80(1) of the Income Tax Ordinance, 1984 (XXXVI of 1984)

1. Mention the amount of assets and liabilities that you have at the last date of the income year. All
items shal be at cost value include legal, registraation and all other related costs:
2. If your spouse or minor children and dependent(s) are not assessee, you have to include their assets
and liabilities in your statement.
3. Schedule 25 is the interal part of this Statement if you have business capital or agriculture or non-
agricultural property. Provide additional papers if necessary.

01 Assessment Year 02 Statement as on (DD-MM-YYYY)

2 0

03 Name of the Assessee 04 TIN

Particulars Amount $
05 Business capital (05A+05B)
05A Business capital other than 05B

05B Director's shareholdings in limited companies (if in Schedule 25)

06 06A Non-agricultural property (as in Schedule 25)

06B Advance made for non-agricultural property (as in Schedule 25)

07 Agricultural property (as in Schedule 25)
08 Financial assets value (08A+08B+08C+08D+08E)

08A Share, deventures etc.

08B Savings certificate, bonds and other government securities

08C Fixed deposit, Term deposits and DPS

08D Loan given to others (mention name and TIN)

08E Other financial assets (give details)

09 Motor car (s) (use additional papers if more than two cars)

SL. Brand Name Engine (CC) Registration No.

1
2
10 Gold, diamond, gems and other items (mention quantity)
11 Furniture, equipment and electronic items

12 Other
2 0assets of significat value

Particulars Amount $

13 Cash and fund outside business (13A+13B+13C+13D)

13A Notes and currencies

13B Bank, cards and other electronic cash
13C Provident fund and other fund

13D Other deposits, balance and advance (other than 08)

14 Gross wealth (aggregate of 05 to 13)

15 Liabilities outside business (15A+15B+15C)

15A Borrowings from banks and other financial institutions
15B Unsecured loan (mention name and TIN)

15C Other loans or overdrafts

16 Net wealth (14-15)

17 Netwealth at the last date of the previous income year

18 Changein net wealth (16-17)

19 Other fund outflow during the income year (19A+19B+19C)

19A Annual living expenditure and tax payment (as IT-10BB2016)
19B Loss, deductions, expenses, etc. not mentioned in IT-10BB2016)

19C Gift, donation and contribution (mention name of recipient)

20 Total fund outflow in the income year (18+19)

21 Sources of fund (21A+22B+23C)

21A Income shown in the return
21B Tax exempted income and allowance

21C Other receipts and sources

22 2 0 of fund, if any (21-22)
Shortage

Verification and signature

23 Verification
I solemnly declare that to the best of my knowledge and belief the information given in this
statement and the schedule annexed herewith are correct and complete.
 Name Signature & Date

SCHEDULE 24D
Particulars of tax credit/rebate
To be annexed to return by an assessee claiming investment tax credit
(Attach the proof of claimed investment, contribution, etc.)

01 Assessment Year 02 TIN

Particulars of rebatable investment, contribution, etc. Amount $

03 Life Insurance

04 Contribution to deposit pension scheme (not exceeding allowabel

limit)
05 Investment in approved savings certificate

06 Investment in approved debenture or debenture stock, Stock or Shares

07 Contribution to provident fund to which Provident Fund Act, 1925

Applies
08 Self contribution and employer's contribution to Recognized Provident

fund.
09 Contribution to Super Annuation Fund

10 Contribution to Benevolent Fund and Group Insurance Premium

11 Contribution to Zakat Fund

12 Others, if any (give details)

13 Total allowable investment, contribution, etc.

14 Eligible amount for rebate (the lesser of 14A, 14B,14C)

14A Total allowable investment, contribution, etc. (as in 13)

2 0
14B ……….% of the total income [excluding any income for which a tax

exemtion or a reduced rate is applicable under sub-section (4) of

section 44 or any income from any source or sources mentioned in

clause (a) of sub-section (2) of section 82C.]

14C 1.5 crore

15 Amount of tax rebate calculated on eligible amount (Serial 14) under

 section 44(2)(b)

Name Signature & Date

National Board of Revenue IT-10B2016

www.nbr.gov.bd
STATEMENT OF EXPENSES RELATING TO LIFESTYLE
under section 80(2) of the Income Tax Ordinance, 1984 (XXXVI of 1984)
01 Assessment Year 02 Statement as on (DD-MM-YYYY)

03 Name of the Assessee 04 TIN

Particulars Amount $ Amount $

05 Expenses for food, clothing and other
essentials
06 Housing expense
07 Auto and transportation expenses (07A+07B)
07A Driver's salary, fuel and maintenance
07B Other transportation
08 Household and utility expenses
(08A+08B+08C+08D)
08A Electricity
08B Gas, water, sewer and garbage
08C Phone, internet, TV channels subsription
08D Home-support staff and others expenses
09 Children's education expenses
10 Special expenses (10A+10B+10C+10D)
10A Festibal, party, events and gifts
10B Domestic and overseas tour, holiday, etc.
10C Donation, philanthropy, etc.
10D Other special expenses
11 Any other expenses
12 Total expense relating to lifestyle
(05+06+07+08+09+10+11)
13 Payment of tax, charges, etc. (13A+13B)
13A Payment of tax at source
13B Payment of tax, surcharge or other
 amount
14 Total amount of expense and tax (12+13)

Verification and signature

15 Verifiation
I solemnly declare that to the best of my knowledge and belief the information given in
this statement iscorrect and complete.
Name Signature & date

National Board of Revenue

www.nbr.gov.bd Individual
ACKNOWLEDGEMENT RECEIPT OF
RETURN OF INCOME

Assessment Year Return under section 82BB?(tick one)

Yes No

Name of the Assessee

Twelve-digit TIN Old TIN

Circle Taxes Zone

Total income shown (serial 34)

$

Amount payable (serial 41) Amount paid and adjusted (serial 46)
$ $

Amount of net wealth shown in IT10B2016 Amount of net wealth surcharge paid
$ $

Date of Submission (DD-MM-YYYY) Tax Office Entry Number

Signature and seal of the official receiving the return

Date of Signature Contact Number of Tax Office

B.G.P-2016/17-18001 Com ©--6,00,000 Copy,
 SCHEDULE-24
Particulars of income from Salaries
Annex this Schedule to the return of income if you have income from Salaries

01 Assessment Year 02 TIN

2 0

Particulars Amoun Tax exemted Taxable

(A) (B) (C=A-B)
03 Basic Salary
04 Special pay

05 Arrear pay (if not included in taxable

income earlier)
06 Dearness allowance
07 House rent allowance

08 Medical allowance
09 Conveyance allownace
10 Festival Allowance

11 Allowance for support staff

12 Leave allowance

13 Honorarium/Reward/Fee
14 Overtime allowance
15 Bonus/ Ex-gratia

16 Other allowances
17 Employer's contribution to a
recognized provident fund
18 Interest accred on a recognized
provident fund
19 Deemed income for transport facility
20 Deemed income for free furnished/
unfurnished accommodation
21 Other, if any (give detail
22 Total

All figures of amount are in taka ($)

Name Signature & Date

 SCHEDULE 24B
Particulars of income from house property
Annex this Schedule to the return of income if you have income from house property

01 Assessment Year 02 TIN

For each house property

03 Desription of the house property

03A Address of the property 03B Total area

03C Share of the asessee(%)

Income from house property Amount $

04 Annual Value

05 Deductions (aggregate of 05A to 05G)

05A Repair, Collection, etc.

05B Municipal or Local Tax

05C Land Revenue

05D Interest on Loan/Mortgage/Capital Charge

05E Insurance Premium

05F Vacancy Allowance

05G Other, if any

06 Income from house property (04-05)

07 In case of partial ownership, the share of income

Provide information if income form more than one house property

08 Aggregate of income of all house properties (1+2+3+ - - -) $
1 (Income form house property 1) $
2 (Income form house property 2) $
3 (Income form house property 3) $

Name Signature & Date

 SCHEDULE 24C
Summaryof income from business or profession
To be annexed to return by an assessee having income from business or profession

01 Assessment Year 02 TIN

2 0

03 Type of main business or profession (as 05 Address(es)

in trade licence)

Use serial numers if more names and addresses

Summary of Income Amount $

06 Sales/Turnover/Receipts

07 Gross Profit

08 General, administrative, selling and other expenses

09 Net Profit (07-08)

Summary of Balance Sheet Amount $

10 Cash in hand & at bank

11 Inventories

12 Fixed assets

13 Other assets

14 Total assets (10+11+12+13)

15 Opening capital

16 Net profit

17 Withdrawals in the income year

18 Closing capital (15+16-17)

19 Liabilities

20 Total capital and liabilities (18+19)

Name Signature & Date

 SCHEDULE 25
to be annexed to the Statement of Assets, Liabilities and Expenses (IT-10B2016)

01 Assessment Year 02 TIN

03 Shareholdings in limited companies as director No. of shares Value $

1

04 Non-agricultural property at cost value Value at the Increased/ Value at the

or any advance made for such property start of decreased last date of
(description, location and size) income year $ during the Income year $
income year $

05 Agricultural property at cost value Value at the Increased/ Value at the

(description, locato and size) start of decreased last date of
income year $ during the Income year $
income year $

4
(Provide additional paper if necessary)

Name Signature & date