INTERNAL REVENUE SERVICE

INCOME TAX FORM FOR RETURN OF INCOME AND

CLAIMS FOR ALLOWANCES AND RELIEFS

GUIDE TO COMPLETING TAX FORM A

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Please ensure that the date fields are properly filled



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Step 2 of 5

PART B : STATEMENT OF INCOME FOR THE YEAR ENDED 31ST DECEMBER 2017

Annex copies of Accounts for the Year Ended 31st Dec. *

(Annex details of each allowance paid on your behalf)

(State name and Address of the Payer)
(Enter the gross Amount before deduction of tax.)
(Annex a list giving details of each source and the gross income received there from)
(Annex a list showing for each property, the amount of gross and other expenses) rent and or premium received there from and their repair rates.
(Y)Agregate investment Income form all Source *
Step 3 of 5

PART C:

(e.g. Maids, Drivers, Gardener, Watchmen, Cooks, Stewards, Cleaners etc.)
Sr.No.NamePhone Number Residental AddressAmount Paid
1
Note: Please asterisk those paid for by your employer or a separate entity apart from self, and annex the details.
Sr.No.Purchase of dateCostBrandModelYear
1
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PART D: OTHER MANDATORY DISCLOSURES

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PART E:RELIEFS AND ALLOWANCES FOR LIFE ASSURANCE, GRATUITIES, NHIS AND PENSION CONTRIBUTION (100% of sum paid)

Life Assurance Premium
Sr.No. Name of Insurance Company Indicate if Contribution is Made on Behalf of Self or Spouse (With Name) Amount Insured Premium Payment for 20XX
1

PENALTY FOR DEFAULT

Please note that in accordance with the relevant laws, making false statements and returns or unlawful refusal/neglect to pay accurate tax will attract fine or imprisonment or both.

DECLARATION WHICH MUST BE COMPLETED AND SIGNED

I hereby declare that information supplied in this form to the best of my knowledge and belief contains correct and complete statement of the amount of income from all sources. I understand that I may have to pay financial penalties and face prosecution if I give false information.

Give Under My Hand, This of