Indian Income Tax Return Verification Form

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Assessment Year
INDIAN INCOME TAX RETURN VERIFICATION FORM
[Where the data of the Return of Income in Forms Saral-II (ITR-1), ITR-2, ITR-3, ITR-
ITR-V
2 0 1 0 - 1 1
4, ITR-5 & ITR-6 transmitted electronically without digital signature]
(Please see Rule 12 of the Income-tax Rules,1962)
(Also see attached instructions)
Name
PAN
Flat/Door/Block No
Name Of Premises/Building/Village
Form No. which
has been
electronically
transmitted
Road/Street/Post Office
Area/Locality
(fill the code)
Town/City/District
State
Status (fill the
code)
Designation of Assessing Officer (Ward/ Circle)
Original or Revised
E-filing Acknowledgement Number
Date(DD/MM/YYYY)
/
/
Gross total income
1
1
Deductions under Chapter-VI-A
2
2
Total Income
3
3
Current Year loss (if any)
3a
3a
Net tax payable
4
4
Interest payable
5
5
Total tax and interest payable
6
6
7 Taxes Paid
a
Advance Tax
7a
b
TDS
7b
c
TCS
7c
d
Self Assessment Tax
7d
e
Total Taxes Paid (7a+7b+7c +7d)
7e
Tax Payable (6-7e)
8
8
Refund (7e-6)
9
9
VERIFICATION
I,
_________________________________________________(full
name
in
block
letters),
son/
daughter
of
____________________________________________, permanent account number __________________solemnly declare that to the
best of my knowledge and belief, the information given in the return and the schedules thereto which have been transmitted
electronically by me vide acknowledgement number mentioned above 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 2010-11. I further declare that I am making this
return in my capacity as ___________ and I am also competent to make this return and verify it.
Sign here
Date
Place
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
For Office Use Only
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