KHADKHAD PRIMARY SCHOOL

Ta. VADIA Dist. AMRELI

SALARY STATEMENT FOR THE FINANCIAL YEAR 2009-10
EMPLOYEE NAME :- DIVYESH SHAMBHUBHAI ANSODARIYA ASSISTANT TEACHER
S5FT
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C[0 :5[P5[
V[,FP S]PSP S], HLP5LPV[O VgI H]Y .gSD G[8 ;[,[ZL
JLDM JLDM jIPJ[ZM 8[1F S],
ZMS0 HDF DM\3JFZL ZMS0 ,MG
1 Apr-09 4600 2300 0 100 3243 345 0 0 10588 5000 0 0 0 100 150 0 5250 5338
2 May-09 4600 2300 0 100 3243 345 0 0 10588 5000 0 0 0 100 150 0 5250 5338
3 Jun-09 8990 2400 0 100 1822 1139 0 0 14451 5000 0 0 0 100 200 0 5300 9151
4 Jul-09 8990 2400 0 100 2506 1139 0 0 15135 5000 683 0 0 100 200 0 5983 9152
5 Aug-09 9340 2400 0 100 2583 1174 0 0 15597 5000 704 0 0 100 200 0 6004 9593
6 Sep-09 9340 2400 0 100 2583 1174 0 0 15597 5000 704 0 0 100 200 0 6004 9593
7 Oct-09 9340 2400 0 100 2583 1174 0 0 15597 5000 704 0 0 100 200 0 6004 9593
8 Nov-09 9340 2400 0 100 3170 1174 0 0 16184 5000 1291 0 0 100 200 0 6591 9593
9 Dec-09 9340 2400 0 100 3170 1174 0 0 16184 5000 1291 0 0 100 200 0 6591 9593
10 Jan-10 9340 2400 0 100 3170 1174 0 0 16184 5000 1291 0 0 100 200 0 6591 9593
11 Feb-10 9340 2400 0 100 3170 1174 0 0 16184 5000 1291 0 0 100 200 0 6591 9593
12 Mar-10 9340 2400 0 100 3170 1174 0 0 16184 5000 1291 0 0 100 200 0 6591 9593
14 DM\3P5]ZJPH],F. 3420 0 3420 3170 250 3420 0
15 DM\3P5]ZJP0L;[P 1761 0 1761 1761 0 1761 0
16 5UFZ 5]ZPH] 3863 0 3863 50 50 3813
17 5UFZ 5]ZJ6L 0 0 0 0
18 VgI 0 0 0 0
19 TOTAL 105763 28600 0 1200 39594 12360 0 0 187517 60000 14181 0 0 1200 2600 0 77981 109536

SD"RFZLGL ;CL SR[ZLGF J0FGL ;CL VG[ ;LSSM

 INCOME - TAX STATEMENT
FOR THE FINANCIAL YEAR 2009-2010
Name of the EmployeeDIVYESH SHAMBHUBHAI ANSODARIYA
Designation ASSISTANT TEACHER D.O.B 29.3.1979
Office Name KHADKHAD PRIMARY SCHOOL
Office Address KHADKHAD Ta. VADIA Dist. AMRELI
INCOME TAX PERMANENT A/C No. (PAN) AFSPA6876M
Rs. Rs. Rs.
1. Estimated Gross Income for the financial
year 2008-2009 Basic Pay 105763
Grade pay 28600
Transport 0
Medical 1200
D.A. 39594
H.R.A. 12360
Head Allow. 0
OTHER 0
TOTAL 187517
2. i) Whether living in a rented house and actually
incurring expenditure on rent.
ii) Deduction in respect of H.R.A. exemption
a) Actual H.R.A. received
b) 10% of salary
c) Actual rent paid
d) Excess rent paid above 10% of salary
e) 40% of salary
f) Least of a,d,e
iii) H.R.A. Deduction U/S 10 (13A) 0
3. Balance [ 1 - 2 (iii) ] 187517
4. LESS: Professional Tax U/S 16 (iii) 2600
5. Gross Total Income [ 3 - 4 ] 184917
6. Other income:- 1. a/c interest 0
2. other 0
7. Net income [ 5 + 6 ] 184917
GROSS QUALIFY
8. Deductions under chapter VI A AMOUNT AMOUNT
a) Medical insurance premium up to Rs. 10000/- 0 0
( Rs. 15000/- if beneficiary is a senior citizen
with age 65 years & above ) U/S 80 D
b) Expenditure on a handicapped dependant, 0 0
max. Rs. 50000/- at flat rate ( Rs. 75000/- in
case of dependent with severe disability )
U/S 80 DD
c) Actual expenditure on assessee / dependant 0 0
patient for treatment of specified diseases
limited to Rs. 40000/- ( Rs. 60000/- in case
of senior citizen, 65 yrs & above) U/S 80 DDB
d) Relief to physically handicapped / mentally 0 0
retarded assessee, Rs. 50000/- ( in case of
divyesh - 9426783304
severe disability, Rs. 75000/- ) U/S 80 U

divyesh - 9426783304
 e) Repayment of Educational loan of assessee, 0 0
max. limited to Rs. 40000/- ( loan & interest )U/S 80 E
f) Interest on House Loans, max. Rs. 30000/- 0 0
for loans before 01-04-1999 & Rs. 150000/-
for loans on or after 01-04-1999.
g) Contribution to specified funds U/S 80 G 0 0
TOTAL 0 0
h) TOTAL QUALIFYING AMOUNT (DEDUCTION) 0
9. Total income [ 7 - 8 (h) ] 184917
10. A) Specified savings qualifying for deduction U/S 80 C
a) G.P.F. 74181
b) A.P.G.L.I. 0
c) L.I.C. & P.L.I. (Salary deduction) 0
d) G.I.S. 1200
e) P.P.F. 0
f) ULIP / LIC, Mutual Funds etc. 0
g) N.S.C. 0
h) Interest on N.S.C. 0
i) House loan repayment. 0
j) Tuition fees paid on children's education 0
k) L.I.C. Premiam paid 0
l) P.L.I. Premiam paid 0
m) Tax Saving Infrastructural Bonds 0
B) Contributions to L.I.C. & other pension schemes U/S 80 CCC 0
TOTAL [ A + B ] 75381
n) TOTAL QUALIFYING AMOUNT 75381
11. a) Total Taxable Income [ 9 - 10 (n) ] 109536
b) Total Taxable Income (rounded to nearest 10/-) 109540
12. a) Income Tax on income at S.No. 11 (b) 0
Up to Rs 160000/- NIL
Rs. 160001/- to 300000/- 10% of amount exceeding 150000/-
Rs. 300000/- to 500000/- Rs. 15000+20% of amount exceeding 300000/-
Rs. 500000/- & above Rs. 55000+30% of amount exceeding 500000/-
b) Surcharge @ 10% of tax payable for income above Rs. 1000000/- 0
c) Educational cess @ 3% of tax payable on (a+b) 0
d) Gross income tax [ a + b + c ] 0
13. a) LESS : Relief on arrears U/S 89 (i) 0
b) Tax Liability during 2008-09 [ 12 (d) - 13 (a) ] 0
14. a) LESS: Tax already deducted up to Dec, 09 0
b) Tax to be deducted from Jan, 09 onwards 0
In Jan,2009 In Feb,2009
Rs. 0 Rs. 0
TAX TO BE PAID THROUGH CHALLAN Rs. 0
CERTIFICATE BY EMPLOYEE
THIS IS TO CERTIFY THAT INFORMATION IN THIS STATEMENT IS CORRECT AND MISTAKLESS.

Date :-
Place :- KHADKHAD Signature of Employee
CERTIFICATE BY OFFICE
THIS IS TO CERTIFY THAT INFORMATION IN THIS STATEMENT COMPAIRED WITH OFFICE RECORD
AS WELL AS DOCOMENT PRESENT BY EMPLOYEE AND FOUND CORRECT.

divyesh - 9426783304
 Date :-
Place :- KHADKHAD Signature of Head of Office

divyesh - 9426783304
 FORM No. 16
[ See rule 31 (1) (a) ]
Certificate under section 203 of Income Tax Act 1961 for tax deducted at source
from income chargeable under the head "Salaries"
Name and Designation
Name and Address of the Employer
of the Employee
HEAD MASTER DIVYESH SHAMBHUBHAI ANSODARIYA
KHADKHAD PRIMARY SCHOOL ASSISTANT TEACHER
KHADKHAD KHADKHAD PRIMARY SCHOOL
Ta. VADIA Dist. AMRELI KHADKHAD Ta. VADIA Dist. AMRELI
GIR No. TAN No. PAN No. AFSPA6876M
T.D.S. Circle where Annual Return / Statement PERIOD Assessment Year
under section 206 is to be filed 1.4.2009 TO 31.3.2010 2010-2011
DETAILS OF SALARY PAID & ANY OTHER INCOME AND TAX DEDUCTED
Rs. Rs. Rs.
1. Gross Salary 187517
2. Less :Allowance to the extent exempted under section10 0
3. BALANCE [ 1 - 2 ] 187517
4. Less : Tax on Employment U/S 16 (iii) 2600
6. INCOME CHARGEABLE UNDER 184917
THE HEAD SALARIES [ 3 - 4 ]
7. Add : Any other income reported by the employee 0
8. GROSS TOTAL INCOME [ 6 + 7 ]
9. DEDUCTIONS UNDER CHAPTER VI A GROSS QUALIFYING
AMOUNT AMOUNT
a) Medical insurance premia paid U/S 80 D 0 0
b) Expenditure on dependants U/S 80 DD 0 0
c) Expenditure on assessee / dependants U/S 80 DDB 0 0
d) Relief to physically handicapped/mentally retirded U/S 80 U 0 0
e) Repayment of Educational loan U/S 80 E 0 0
f) Interest on House Loans 0 0
g) Contribution to specified funds U/S 80 G 0 0
TOTAL 0 0
10. Aggregate of deductible amount under Chapter VI A 0
11. Total Income [ 8 - 10 ]
12. A) Specified savings qualifying for deduction U/S 80 C
a) G.P.F. 74181
b) A.P.G.L.I. 0
c) L.I.C. & P.L.I. (Salary deduction) 0
d) G.I.S. 1200
e) P.P.F. 0
f) ULIP / LIC, Mutual Funds etc. 0
g) N.S.C. 0
h) Interest on N.S.C. 0
i) House loan repayment. 0
j) Tuition fees paid on children's education 0
k) L.I.C. Premia paid 0
l) P.L.I. Premia paid 0
m) Tax Saving Infrastructural Bonds 0
B) Contributions to L.I.C. & other pension schemes U/S 80 CCC 0
 TOTAL [ A + B ] 75381
n) TOTAL QUALIFYING AMOUNT 75381
13. a) Total Taxable Income [ 11 - 12 (n) ]
b) Total Taxable Income (rounded to nearest 10/-)
14. a) Income Tax on income at S.No. 13 (b)
b) Surcharge @ 10% of tax payable for income
above Rs. 1000000/-
c) Educational cess @ 3% of tax payable on (a+b)
d) Gross income tax [ a + b + c ]
15. a) LESS : Relief on arrears U/S 89 (i)
b) Tax Liability during 2007-08 [ 14 (d) - 15 (a) ]
16. LESS : TAX DEDUCTED AT SOURCE
17. TAX PAYABLE
DETAILS OF TAX DEDUCTED AND DEPOSITED INTO CENTRAL GOVERNMENT ACCOUNT
AMOUNT Rs. MONTH / DATE OF NAME OF THE BANK BRANCH WHERE TAX DEPOSITED
PAYMENT

0 Sep-09 ----
0 Oct-09 ----
0 Nov-09 ----
0 Dec-09 ----
0 Jan-10 ----
0 Feb-10 ----
0 T.D.S. ON CAS & OTHER ARREARS
0 TOTAL TAX DEDUCTED AT SOURCE

Certified that a sum of Rs. ( in words ) … only

has been deducted at source and paid to the credit of Central Government. Further certified that the above
information is true and correct as per records

Signature of the person responsible for deduction of tax

Place : KHADKHAD Full name :
Date : Designation :
Note : See sections 15 and 17 and rule 3. Furnish separate details of value of perquisites and profits
in lieu of or in addition to salary or wages
divyeshsansodariya@rediff.com
ce

nation
yee
NSODARIYA

Dist. AMRELI
AFSPA6876M
ssessment Year
2010-2011
UCTED
Rs.

184917

184917
 109536
109540
0
0

0
0
0
0
0
0
NT ACCOUNT
TAX DEPOSITED

EARS
OURCE

rtified that the above

duction of tax

d profits

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

First name Middle name Last name PAN

DIVYESH SHAMBHUBHAI ANSODARIYA AFSPA6876M
Flat / Door / Block No. Name of Premises / Building / Village Date of Birth (DD/MM/YYYY)
PERSONAL INFORMATION

KHADKHAD 29.3.1979
Road / Street / Post Office Area / Locality Employer Category (Tick) a

√ Govt PSU Others

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

AMRELI GUJARAT 3 6 5 4 8 0 √ Male Female

Email address (STD code) - Phone number

-
Designation of the Assessing Officer (Ward / Circle) Return Filed Under Section -
[Please see instruction number 9(i)]
FILING STATUS

Whether original or Revised Return ? (Tick) a √ Original Revised

If revised enter Receipt No. and date of filing original

/ /
return (DD/MM/YYYY)

Residential Status (Tick) a √ Resident Non-Resident Resident but Not Ordinarily Resident

1 Income Chargeable under the Head 'Salaries' (Salary / Pension) 1 184917

2 Income Chargeable under the Head 'Other Sources' 2 0
INCOME & DEDUCTIONS

3 Gross Total Income (1+ 2c) 3 184917

4 Deduction under Chapter VI A (Section)
a 80C 75381 e 80DD i 80GG
b 80CCC f 80DDB j 80GGA
c 80CCD g 80E k 80GGC
d 80D 0h 80G 0l 80U 0
m Deductions ( Total of a to l) 4m 75381
5 Total Income (3 - 4m) 5 109536
6 Net Agricultural Income (Enter only if greater than Rs. 5,000) 6 0
7 'Aggregate Income' (5 + 6 ) 7 109536
8 a Tax Payable on 'Aggregate Income' 8a 0
b Rebate in respect of Net Agricultural Income 8b 0
TAX COMPUTATION

9 a Tax Payable on Total Income (8a - 8b) 9a 0

b Surcharge on 9a 9b 0
c Education Cess on (9a + 9b) 9c 0
d Total Tax, Surcharge and Educational Cess Payable (9a + 9b + 9c) 9d 0
10 Relief under section 89 10 0
11 Relief under section 90 / 91 11
12 Balance Tax Payable (9d - 10 - 11) 12 0
Do not write or stamp in this area (Space for bar code) For Office Use only Seal and signature of the receiving official

Receipt No.

Date
 13 a Interest Payable U/S 234 A 13a 0
b Interest Payable U/S 234 B 13b 0
c Interest Payable U/S 234 C 13c 0
d Total Interest Payable (13a +13b + 13c) 13d 0
Total Tax and Interest Payable
14
(12 + 13d) 14 0
15 Taxes Paid
a Advance Tax (from item 23) 15a 0
TAXES PAID

b TDS (column 7 of item 21 + column 7 of item 22) 15b 0

c Self Assessment Tax (from item 23) 15c 0
d Total Taxes Paid (15a + 15b + 15c) 15d 0
16 Tax Payable (14 - 15d) (Enter if 14 is greater than 15d , else leave blank) 16 0
17 Refund (15d -14) (Enter if 15d is greater than 14, also give Bank Account details below) 17 0
18 Enter your bank account number (mandatory in case of refund)
REFUND

19 Do you want your refund by √ Cheque, or Deposited directly into your bank account? (tick as applicable) a

20 In case of direct deposit in your bank account give additional details

MICR CODE Type of account (tick as applicable) a √ Savings Current

21 Details of Tax Deducted at Source from Salary [as per Form 16 issued by Employer(s)]
Sl Tax deduction Account Number (TAN) of Name and address of the Employer Income Deduction Tax payable (incl. Total tax Tax payable /
No the Employer chargeable under Chapter surch. and edn. deposited refundable
TDS ON SALARY

. under the head VI-A cess)

Salaries
(1) (2) (3) (4) (5) (6) (7) (8)
i HEAD MASTER
R K T T 0 0 6 8 9 D KHADKHAD PRIMARY SCHOOL
184917 75381 0 0 0
ii

22 Details of Tax Deducted at Source on Interest [as per Form 16A issued by Deductor(s)]
Sl Tax deduction Account Number (TAN) of Name and address of the Deductor Amount paid / credited Date of payment / credit Total tax Amount out of
No the Deductor deposited (6) claimed for
this year
TDS ON INTEREST

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

i

ii

iii

Note Enter the total 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 Name of Bank & Branch BSR Code Date of Deposit Serial No. of 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. 15a and 15c of TAXES PAID

24 Other Information (transactions reported Through Annual Information Return) (Please see instruction number -9(ii) for code)
Sl code Amount (Rs) Sl code Amount (Rs) Sl code
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

26 E-filing Acknowledgement Number Date (DD/MM/YYYY) / /

VERIFICATION
I. DAFDA KANTIBHAI KHODABHAI son / daughter of solemnly
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 2009-10

Place KHADKHAD Date Sign Here

27 If the return of Income has been prepared by a Tax Return Preparer (TRP) give further details as below:
Identification No. of TRP Name of TRP Counter sign by TRP
If TRP is entitled for any reimbursement from the Government, amount thereof (to be filled by TRP) 28
FORM NO.2D
SARAL ITS-2D
[*INCOME-TAX RETURN FORM FOR NON CORPORATE ASSESSEES OTHER THAN
PERSONS CLAIMING EXEMPTION UNDER SECTION 11 ]
[ See proviso to rule 12( I )( b ) ( III )]
1. NAME : DIVYESH SHAMBHUBHAI ANSODARIYA
2. OFFICE NAME KHADKHAD PRIMARY SCHOOL
3. ADDRESS : KHADKHAD Ta. VADIA Dist. AMRELI
PIN : TELEPHONE :
4. Permanent Account Number : AFSPA6876M 8. Ward/Circle/Special Range :
5. Date of Birth 29.3.1979 9. SEX : Male / Female MALE
6. Individual/Hindu Undevided 10. Income for the year i.e. 2009-2010
family
Association / firm / / Local
of Persons INDIVIDUAL
11. Assessment Year 2010-2011
authority
7. Resident :- INDIAN 12. Return Original or Revised : ORIGINAL
13. Details of Bank Acconts :
Name of the Bank Address of the Bank Account Number

*Please tick[ ] the bank account,where you would like the amount of refund to be credited
14. Details of Credit Card :
15. INCOME FROM SALARY ( ATTACH FORM NO.16 ) 701 Rs. 184917.00
16. INCOME FROM HOUSE PROPERTY 702 Rs.
17. INCOME FROM BUSINESS OR PROFESSION 703 Rs.
18. CAPITAL GAINS 15/9 15/12 15/3 31/3 TOTAL
( a ) Short term 645 646 647 648 704
( b ) Long term 695 696 697 698 705 776 Rs.
19. INCOME FROM OTHER SOURCES 706 Rs. 0.00
20. INCOME OF ANY OTHER PERSON TO BE ADDED 775 Rs.
21. GROSS TOTAL INCOME (15+16+17+18+19+20) 746 Rs. 184917.00
22. LESS : DEDUCTION UNDER CHAPTER VI-A : SECTION Rs.
Code (For Office Use) Section Amount(Rs.)
(a) 80 C 75381
(b) 80 D 0
(c) 81 U 0 747 Rs. 75381.00
23. TOTAL INCOME : (21 - 22 ) 760 Rs. 109536.00
24. ADD : AGRICULTRAL INCOME ( For rate purpose ) 762 Rs.
25. INCOME CLAIMED TO BE EXEMPT FROM INCOME TAX 125 Rs.
26. TAX ON TOTAL INCOME INCOME INCOME TAX
( a ) At normal rates 772 109540.00 802 0.00
( b ) At special rates 768 801 810 Rs. 0.00
27. LESS : REBATE 820 Rs.
28. TAX PAYABLE 826 Rs. 0.00
29. ADD SURCHARGE 828 Rs. 0.00
30. TOTAL TAX PAYABLE (28+29) 832 Rs. 0.00
31. LESS : RELIEF 837 Rs. 0.00
32. NET TAX PAYABLE 840 Rs. 0.00
33. LESS : TAX DEDUCTED AT SOURCE 840 Rs. 0.00
34. LESS : ADVANCE TAX PAID 873 Rs.
Date Date Date
Amount Amount Amount 862 Rs.
35. ADD : INTEREST PAYABLE U/s 234 234B 234C Total 851 Rs.
36. LESS : SELF ASSESSMENT TAX PAID 875 Rs.
37. BALANCE TAX : PAYABLE / REFUNDABLE 891 Rs. 0.00
DOCUMENTS ATTACHED WITH THE RETURN
1. Form No. 16 (Original) 2. TDS Certificate
3. 4.
VERIFICATION
I, DIVYESH SHAMBHUBHAI ANSODARIYA ( name in full and in block letters),
son / daughter of solemniy declare that to the best of my knowledge
and belief, the information given in this return and the annexures and statements accompanying it are correct.,complete
and truly stated and in accordance with the provisions of Income Tax Act. 1961, in respect of income chargeble to
income tax for the previous year relevant to the assessment year 2010-2011

Receipt No. Date

Signature
Seal Date :
Signature of the receiving official Place : AMARNAGAR
 GOVERNMENT OF INDIA
INCOM TAX DEPARTMENT

ACKNOWLEDGEMENT

Received with thanks form: DIVYESH SHAMBHUBHAI ANSODARIYA a return of income and/or
return of fringe benefits in Form No ITR - 1 for assessment year 2010-2011,having the following particulars:
PERSONAL INFORMATION

Name PAN NO.

DIVYESH SHAMBHUBHAI ANSODARIYA AFSPA6876M
Flat/Door/Block No: Name of Premises/Building/Village:
KHADKHAD
Road/Street/Post Office: Area/Locality:

Town/City/District: State:
AMRELI GUJARAT
1 Gross total income 1 184917
COMPUTATION OF INCOME & TAX THEREON

2 Deduction under Chapter-VI-A 2 75381

3 Total Income 3 109536
4 Net tax payable 4 0
5 Interest payable 5 0
6 Total tax and interest payable 6 0
7 Taxes paid
a Advance Tax 7a 0
b TDS 7b 0
c TCS 7c 0
d Self Assessment Tax 7d 0
e Total Taxes paid (7a+7b+7c+7d) 7e 0
8 Tax payable (6-7e) 8 0
9 Refund (7e-6) 9 0
10 Value of Fringe Benefits 10 0
FringeBenefits & Tax Thereon

11 Total fringe benefit tax liability 11 0

Computation of Income &

12 Total interest payable 12 0

13 Total tax and interest payable 13 0
14 Taxes paid
a Advance Tax 14a 0
b Self Assessment Tax 14b 0
c Total Taxes paid (14a+14b) 14c 0
15 Tax payable (13-14c) 15 0
16 Refund (14c-13) 16 0
Receipt No. Seal and Signature of receiving official:
Date: