IT-11GA2016
National Board of Revenue
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:
Photo
Schedule 24A
if you have income from Salaries
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 I
Basic information
01
Assessment Year
2
2
0
0
2
1
-
02
Return submitted under section 82BB? (tick one)
Yes
No
√
03
Name of the Assessee: Takeshi Saito
04
Gender (tick one)
F
M
√
05
Twelve-digit TIN: 765733870541
06
Old TIN: N/A
07
Circle: 227 (Company)
08
Zone: 11 Dhaka.
09
Resident Status (tick one)
Resident
√
Non-resident
10
Tick on the box(es) below if you are:
10A
A gazetted war-wounded
freedom fighter
10B
A person with disability
10C
Aged 65 years or more
10D
A parent/legal guardian of a person
with disability
11
Date of birth (DD-MM-YYYY)
4
3
0
0
1
9
5
9
12
Income Year
2020
to
2021
13
If employed, employer’s name: Nippon Signal Company Limited
14
Spouse Name
15
Spouse TIN (if any)
16
Father’s Name: Hiroyoshi Saito
17
Mother’s Name: Toyo Saito
18
Present Address: Park Road, House-25, Apt-A4, Baridhara, Gulshan, Dhaka, PO : 1212
19
Permanent Address: 1519-2, Ishinada, Utsunomiya, Tchigi, Japan
20
Contact Telephone:
21
E-mail:
22
NID/ Passport: TR9354389
23
Business Identification Number(s)
PART II
Particulars of Income and Tax
TIN:
7
6
5
7
3
3
8
7
0
5
4
1
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
3,440,694
PART III
Instruction, Enclosures and Verification
TIN:
7
6
5
7
3
3
8
7
0
5
4
1
49
Instructions
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 exempted 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 statements and other documents where applicable
50
If you are a parent of a person with disability, has your spouse availed the extended tax exemption threshold? (tick one)
Yes
No
√
51
Are you required to submit a statement of assets, liabilities and expenses (IT-10B2016) under section 80(1)? (tick one)
Yes
No
√
52
Schedules annexed
(tick all that are applicable)
24A
√
24B
24C
24D
53
Statements annexed
(tick all that are applicable)
IT-10BB2016
IT-10B2016
54
Other statements, documents, etc. attached (list all)
Tax Calculation Sheet;
Work Permit;
TIN Certificate;
Previous Tax Clearance Certificate;
Copy of Resignation & Release Letter;
Copy of SRO;
Power of Attorney; and
Passport Copy.
Verification and signature
55
Verification
I solemnly declare that to the best of my knowledge and belief the information given in this return and statements and documents annexed or attached herewith are correct and complete.
Name: Mohammad Riad Siddique, ITP
Authorized Representative
Signature
Date of Signature (DD-MM-YYYY)
2
0
2
1
Place of Signature: Dhaka.
For official use only
Return Submission Information
Date of Submission (DD-MM-YYYY)
2
0
2
1
Tax Office Entry Number
Individual
National Board of Revenue
www.nbr.gov.bd
ACKNOWLEDGEMENT RECEIPT OF
RETURN OF INCOME
Assessment Year
2
2
0
0
2
1
-
Return under section 82BB? (tick one)
Yes
No
√
Name of the Assessee: Takeshi Saito
Twelve-digit TIN: 765733870541
Old TIN
Circle: 227 (Company)
Taxes Zone: 11, Dhaka.
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)
2
0
2
1
Tax Office Entry Number
Signature and seal of the official receiving the return
Date of Signature
Contact Number of Tax Office