RETURN OF TOTAL INCOME/STATEMENT OF FINAL TAXATION

UNDER THE INCOME TAX ORDINANCE, 2001 (FOR INDIVIDUAL / AOP)

Taxpayer's Name
CNIC (for Individual)
Business Name
Registration (*)

Business Address
Res. Address
E-Mail Address Phone

Principal Activity Code

Employer NTN Name

Representative NTN Name

Authorized Rep. NTN Name

L TAXATION
UAL / AOP) N°
Control Centre
NTN
Gender Male ü Female 1 Enter 1 for Male or 2 for Female
Year Ending 30.06.2012
Tax Year 2012
Person IND ü AOP 1 Enter 1 for IND or 2 for AOP
Res. Status Non-Res. ü Resident 2 Enter 1 for Resident or 2 for Non-Resident
Birth Date
Filing Section

RTO/LTU
Is authorized Rep. applicable? Yes/No ü 1 Enter 1 for YES 2 for NO
 Version
Source
Wealth Statement Filled

2 for Non-Resident
 1.0
Turbo Tax Assistant
0
 RETURN OF TOTAL INCOME/STATEMENT OF FINAL TAXATION IT-2 (Page 1 of 2)
UNDER THE INCOME TAX ORDINANCE, 2001 (FOR INDIVIDUAL / AOP) N°
Taxpayer's Name 0 NTN 0
CNIC (for Individual) 0 Gender Male ü Female

Business Name 0 Year Ending 30.06.2012

2012
Registration

Business Address 0 Tax Year

Res. Address 0 Person IND ü AOP

E-Mail Address 0 Phone 0 Res. Status Non-Res. ü Resident

Principal Activity 0 Code 0 Birth Date 0

Employer NTN 0 Name 0 Filing Section 0
Representative NTN 0 Name 0 RTO/LTU 0
Authorized Rep. NTN 0 Name 0 Is authorized Rep. applicable? Yes/No ü
NTN Proprietor/Member/Partners' Name % in Capital Capital Amount
Ownership

Others
Total 100%
Items Code Total
1 Net Sales (excluding Sales Tax/ Federal Excise Duty & Net of Commission/ Brokerage) [to be reconciled with Annex-C] 3103
Manufacturing/ Trading, Profit & Loss
Account ( including Final/Fixed Tax)

2 Cost of Sales [3 + 4 + 5 - 6] [to be reconciled with Annex-C] 3116 0

3 Opening Stock 3117
4 Net Purchases (excluding Sales Tax/ Federal Excise Duty & Net of Commission/ Brokerage) 3106
5 Other Manufacturing/ Trading Expenses [ Transfer from Sr-7 of Annex-G] 3111 0
6 Closing Stock 3118
7 Gross Profit/ (Loss) [1-2] [ to be reconciled with Annex-C ] 3119 0
8 Transport Services U/S 153(1)(b) (Transferred from 40(c)) 3121 0
9 Other Services U/S 153(1)(b) (Transferred from 40(d)) 3122 0
10 Other Revenues/ Fee/ Charges for Professional and Other Services/ Commission 3131
11 Profit & Loss Expenses Transfer from Sr-24 of Annex-G] 3189 0
12 Net Profit/ (Loss) [(7 + 8 + 9 + 10) - 11] 3190 0
13 Inadmissible Deductions [Transfer from Sr-22 of Annex-E] 3191 0
Adjustments

14 Admissible Deductions [Transfer from Sr-5 of Annex-E] 3192 0

15 Unadjusted Loss from business for previous year(s) [Transfer from Sr. 27 of Annex-A] 3902 0
16 Un-absorbed Tax Depreciation for previous/ current year(s) [Transfer from Sr. 27 of Annex-A] 3988 0
17 Total Income [Sum of 18 to 23] 9099 0
18 Salary Income 1999
19 Business Income/ (Loss) [ (12 + 13) - 14 - 15 - 16 ] 3999 0
20 Share from AOP [Income/(Loss)] 312021
21 Capital Gains/(Loss) u/s 37 4999
Total / Taxable Income Computation

22 Other Sources Income/ (Loss) 5999

23 Foreign Income/ (Loss) 6399
24 Deductible Allowances [25 + 26 + 27 + 28] 9139 0
25 Zakat 9121
26 Workers Welfare Fund (WWF) 9122
27 Workers Profit Participation Fund (WPPF) 9123
28 Charitable donations admissible as straight deduction 9124
29 Taxable Income/ (Loss) [17 - 24] 9199 0
30 Exempt Income/ (Loss) [Sum of 31 to 37] 6199 0
31 Salary Income 6101
32 Property Income 6102
33 Business Income/ (Loss) 6103
34 Capital Gains/(Loss) 6104
35 Agriculture Income 6106
36 Foreign Remittances (Attach Evidence) 6107
37 Other Sources Income/ (Loss) 6105
38 Tax chargeable on Taxable Income @ 9201 0
39 Tax Reductions/Credits/Averaging (including rebate on Bahbood Certificates, etc.) 9249
40 Difference of minimum Tax Chargeable on business transactions [40(e)(v) minus 40(e)(iii)]
(i) (ii) (iii) (iv) (v)
Import
Value/Services Proportionate
receipts subject to Proportionate Higher of (iii)
collection or Chargeable
tax* Rate Minimum tax
or (iv)
deduction of tax at income
source

(a) Import of Edible Oil U/S 148(8) 0 3% 0 0 9303 0

(b) Import of Packing Material U/S 148(8) 0 5% 0 0
(c)
Tax Computation

Transport Services U/S 153(1)(b) 0 2% 0 0

(d) Other Services U/S 153(1)(b) 0 6% 0 0
(e) Total 0 0 0 0 0
* [(38 minus 39) divided by 29 multiply by 40(a)(ii) or 40(b)(ii) or 40(c)(ii) or 40(d)(ii), as the case may be]
41 Minimum tax on electricity consumption under section 235(4)
9304
Amount of tax collected along with electricity bill where the monthly bill amount is up to Rs. 30,000
42 Balance tax chargeable [ (38 minus 39 plus 40) or 41, whichever is higher 9305 0
43 Minimum Tax Payable U/S 113 [43(iv) minus 41, if greater than zero, else zero]
(i) Total Turnover (iii) Reduction @ - 9306 0
(ii) Minimum tax @ 1% - (iv) Net Minimum tax -
44 Net tax chargeable [42 + 43 + 90] 9307 0
45 Total Tax Payments (Transfer from Sr. 28 of Annex-B) 9499 0
46 Tax Payable/ Refundable [44 - 45 + WWF Payable from Sr. 29 of Annex-B] 9999 0
47 Refund Adjustments (not exceeding current year's tax payable) 9998
48 Annual personal expenses for individual only (transfer from Sr. 12 of Annex-D) 6109 0
Net Tax Refundable, may be credited to my bank account as under:
Refund

A/C No.

Bank Branch Name & Code Signature

 RETURN OF TOTAL INCOME/STATEMENT OF FINAL TAXATION IT-2 (Page 2 of 2)
UNDER THE INCOME TAX ORDINANCE, 2001 (FOR INDIVIDUAL / AOP) N°
Taxpayer's Name 0 NTN 0
CNIC (for Individual) 0 Tax Year 2012
Business Name 0 RTO/LTU 0
Rate
Source Code Receipts/Value (%) Code Tax Chargeable

49 Imports 64013 5 92013 -

50 64011 2 92011 -
51 64012 1 92012 -
52 64015 3 92015 -
53 Dividend 64032 10 92032 -
54 64033 7.5 92033 -
55 Profit on Debt 64041 10 92041 -
56 Royalties/Fees (Non-Resident) 640511 15 920511 -
57 640512 920512 -
58 Contracts (Non-Resident) 640521 6 920521 -
59 Insurance Premium (Non-Resident) 640524 5 920524 -
60 Advertisement Services (Non-Resident) 640525 10 920525 -
Final Tax

61 Supply of Goods 640611 3.5 920611 -

62 640612 1.5 920612 -
63 640613 920613 -
64 Payments to Ginners 640614 1 920614 -
65 Contracts (Resident) 640631 6 920631 -
66 640632 1 920632 -
67 Exports/related Commission/Service 640641 0.5 920641 -
68 64072 1 92072 -
69 Foreign Indenting Commission 64075 5 92075 -
70 Prizes/Winnings of cross word puzzles 64091 10 92091 -
71 Winnings - Others 64092 20 92092 -
72 Petroleum Commission 64101 10 92101 -
73 Brokerage/Commission 64121 10 92121 -
74 Advertising Commission 64122 5 92122 -
75 Services to Exporters u/s 153(2) 64123 1 92123 -
76 Goods Transport Vehicles 92141

77 Gas consumption by CNG Station 64142 4 92142 -

78 Distribution of cigarette and pharmaceutical products 64143 1 92143 -
79 Retail Turnover upto 5 million 310102 1 920202 -
80 Retail Turnover above 5 million 310103 920203 -
81 Property Income 210101 920235 -
82 Capital gains on Securities held for < 6 months 610401 10 961041 -
83 8 -
Fixed Tax

Capital gains on Securities held for >= 6 months and < 12 months 610402 961042

84 Capital gains on Securities held for >= 12 months 610403 0 961043 -

85 Purchase of locally produced edible oil 310431 2 920208 -
86 Flying Allowance 112001 2.5 920234 -
87 Monetization of Transport Facility For Civil Servants 112002 5 920237 -
Services rendered / contracts executed -
88 63311 0.50 920236
outside Pakistan -
89 Employment Termination Benefits 118301 920211

90 Final/Fixed Tax Chargeable (49 to 89) 9202 -

I,
holder of CNIC No. , in my capacity as
Acknowledgement
Verification

Self/ Partner or Member of Association of Persons/ Representative (as defined in section 172 of the Income
Tax Ordinance, 2001) of Taxpayer named above, do solemnly declare that to the best of my knowledge
and belief the information given in this Return/Statement u/s 115(4) and the attached Annex(es),
Statement(s), Document(s) or Detail(s) is/are correct and complete in accordance with the provisions of the
Income Tax Ordinance, 2001 and Income Tax Rules, 2002 (The alternative in the verification, which is not
applicable, should be scored out).
Signatures & Stamp
Date : Signatures: of Receiving Officer with Date
 Rate Extent
Description Code WDV (BF) Additions Deletions (%) Initial Allowance Rate (%) (%) Depreciation WDV (CF)

Annex-A
1 Building (all types) 3202 50% - 10% - -

2012
2 Machinery and plant (not otherwise specified) 320301 50% - 15% - -
3 Computer hardware (including allied items) 320302 50% - 30% - -
4 Furniture (including fittings) 320303 0% - 15% - -

0
5 Technical and professional books 320304 50% - 15% - -

Tax Year
6 Below ground installations of mineral oil concerns 320306 50% - 100% - -
7 Off shore installations of mineral oil concerns 320307 50% - 20% - -

Depreciable Assets 8 Machinery and equipment used in manufacture of IT pro 320308 50% - 30% - -
9 Motor vehicles (not plying for hire) 32041 0% - 15% - -
10 Motor vehicles (plying for hire) 32042 50% - 15% - -
11 Ships 32043 50% - 15% - -
12 Air crafts and aero engines 32044 50% - 30% - -
Machinery and equipment Qualifying for 1st year
320309 90% 15%
13 Allowance - - -
Computer hardware including printer, monitor and allied items, 320312 0% 50%
Depreciation, Initial Allowance and Amortization

14 that have been used previously in Pakistan - - -

Any plant or machinery that has been used previously 320310 0% 15%
15 in Pakistan - - -
16
Any plant or machinery in relation to which a deduction
has been allowed under another section for the entire 320311 0% 15%
cost of the asset in the tax year in which the asset is
acquired. - - -
Reg/Inc/CNIC No.

Total - - - - - -
Useful Extent
Description Code Acquisition Date Original Cost . Amortization
Life(Years) (%)
Intangibles

17 Intangibles 3205
18 Expenditure providing long term advantage/benefit 3207
19 Total - -
Original
Description Code Expenditure . Rate (%) Amortization
20 Pre commencement expenditure 3206 20%
Description Code Amount Tax Year Description Code Amount Tax Year

Unadjusted Business loss for previous year adjusted Unabsorbed Amortization of intangibles / expenditure
3902 2006
against Business income for current year providing long term advantage/benefit for previous year(s)
21 adjusted against Total Income for current year 3987 upto 2011
Brought Forward Adjustments

Unadjusted Business loss for previous year adjusted Amortization of intangibles / expenditure providing long
3902 2007
against Business income for current year term advantage/benefit for current year adjusted against
22 Total Income for current year 3987 2012

Unadjusted Business loss for previous year adjusted Unabsorbed tax depreciation/initial allowance of fixed
3902 2008 assets for previous year(s) adjusted against Total Income
against Business income for current year
23 for current year 3988 upto 2011

Unadjusted Business loss for previous year adjusted

0

3902 2009 Depreciation/initial allowance of fixed assets for current

against Business income for current year
24 year adjusted against Total Income for current year 3988 2012
Unadjusted Business loss for previous year adjusted
3902 2010
25 against Business income for current year
Unadjusted Business loss for previous year adjusted
3902 2011
26 against Business income for current year
NTN

Total (Not exceeding the amount of Business Income available for Total (Not exceeding the amount of Total Income available for
27 adjustment) (transfer to Sr. 15 of Main Return) - adjustment) (transfer to Sr. 16 of Main Return) -
 Annex-B 2012
Tax Already Paid B
NTN 0 CNIC (for individual) 0
Amount of Tax
Particulars Code
deducted (Rs.)
1 On import of goods (other than tax deduction treated as final tax) 94019
2 From salary 94029
3 On dividend Income (other than tax deduction treated as final tax) 94039
4 On Government securities 94043
5 On profit on debt (other than tax deduction treated as final tax)
94049
Certificate/Account No. etc. Bank Branch Share% -

6 On payments received by non-resident (other than tax deduction treated as final tax) 940539
7 On payments for goods (other than tax deduction treated as final tax) 940619
8 On payments for services (other than tax deduction treated as final tax) 940629
Tax Collected/Deducted at Source (Adjustable Tax only)

9 On payments for execution of contracts (other than tax deduction treated as final tax) 940639
10 On property income 940640
11 On withdrawal from pension fund 94028
12 On cash withdrawal from bank
94119
Certificate/Account No. etc. Bank Branch Share% -

13 On certain transactions in bank 94120

14 With Motor Vehicle Registration Fee
94179
Registration No. Engine / Seating Capacity Owner's Name Manufacturer Particulars -

15 On sale/purchase of shares through a Member of Stock Exchange 94131

16 On trading of shares through a Member of Stock Exchange 94138
17 On financing of carry over trade 94139
18 With motor vehicle token tax (Other than goods transport vehicles)
94149
Registration No. Engine / Seating Capacity Owner's Name Share% -

19 With bill for electricity consumption

94159
Consumer No. Subscriber's CNIC Subscriber's Name Share% -

20 With telephone bills, mobile phone and pre-paid cards

94169
Number Subscriber's CNIC Subscriber's Name Share% -

21 On Sale by Auction 94180

22 On purchase of domestic air travel ticket 94121
23 Total Tax Deductions at source (Adjustable Tax) [Sum of 1 to 22] 94599 -
24 Total Tax Deductions at source (Final Tax) 94591

25 Advance Tax U/S 147(1) [ a + b + c + d] 9461 -

a. First installment CPR No.
b. Second installment CPR No.
Tax Payments

c. Third installment CPR No.

d. Fourth installment CPR No.
26 Advance Tax U/S 147(5B) [ a + b + c + d] 9461 -
a. First installment CPR No.
b. Second installment CPR No.
c. Third installment CPR No.
d. Fourth installment CPR No.
27 Admitted Tax Paid U/S 137(1) CPR No. 9471
28 Total Tax Payments [23 + 24 + 25 + 26+27] (Transfer to Sr. 45 of Main Return) -
WWF Payable with Return (WWF payable will be
29 adjusted against the excess payments made during the 9308
current year)

Note-1 : Grey blank fields are for official use

 Annex C 2012
Breakup of Sales in case of Multiple Businesses C
Taxpayer Name 0 NTN 0
CNIC/Reg.No. 0 Tax Year 2012
Business Name 0 RTO/LTU 0

Business Name & Business Activity Sales Cost of Sales Gross Profit/Loss
Sr.
(1) (2) (3) (4) = (2) - (3)

Business Name
1 -
Business Activity
BUSINESS WISE BREAKUP OF SALES

Business Name
2 -
Business Activity

Business Name
3 -
Business Activity

Business Name
4 -
Business Activity

Business Name
5 -
Business Activity

Total (to be reconciled with Sr. 1, 2 & 7 of Main Return) - - -

Signature:
Note : Grey blank fields are for official use
 Annex - D 2012
Details of Personal Expenses (for individual) D

Taxpayer Name 0

NTN 0 CNIC (for individual) 0

Sr Description Expenses

1 Residence electricity bills

2 Residence telephone/mobile/internet bills

3 Residence gas bills

4 Residence rent/ground rent/property tax/fire insurance/security services/water bills

PERSONAL EXPENSES

5 Education of children/ spouse/ self (Optional, it can be included in Sr-9)

6 Travelling (foreign and local) (Optional, it can be included in Sr-9)

7 Running and maintenance expenses of Motor vehicle(s)

8 Club membership fees/bills

9 Other personal and household expenses

10 Total personal expenses (Sum of 1 to 9) 0

11 (Less) Contribution by family members

12 Net Personal Expenses (10 - 11) transfer to Sr-48 of Main Return 0

Adults Minor
13 Number of family members/dependents

Signature: _____________________
 Annex - E 2012
Deductions (Admissible & Inadmissible)
E
Taxpayer Name 0
NTN 0 CNIC (for individual) 0
Sr. Particulars Code Amount (Rs.)
Admissible Deductions

1 Tax Amortization 319287

2 Tax Depreciation 319288

3 Income/(Loss) relating to Final and Fixed tax [Transfer from Annex-F] 319289

4 Other Admissible Deductions 319298

5 Total [Add 1 to 4] to be transferred to Sr-14 of main return 3192 -

1 Cess, rate or tax that is levied on the profits or gains or assessed as a percentage or otherwise on the basis of profits or gains 319101
Salary, rent, brokerage or commission, profit on debt, payment to non-resident, payment for services or fee from which the
2 company was liable to deduct tax at source unless the company has deducted and paid the tax as required by the Income Tax 319102
Ordinance, 2001
3 Entertainment expenditure in excess of prescribed limits 319104

4 Contribution to an un-recognized provident fund, pension fund, superannuation fund or gratuity fund 319105

Contribution to a provident fund or other fund established for the benefit of the employees, unless effective arrangements have
5 been made to deduct tax at source in respect of which the recipient is chargeable to tax under the head "salary"
319106
Deductions not allowed / inadmissible

6 Fine or penalty for the violation of any law, rule or regulation 319107

7 Personal expenditure 319108

8 Provisions or amounts carried to reserves or funds etc. or capitalised in any way 319109

9 Profit on debt, brokerage, commission, salary or other remuneration paid by an AOP to its members 319110

Any salary, rent, brokerage or commission, profit ondebt, payment to non-resident or payment for services or fee on which tax
10 was required to be deducted and paid but was not deducted and paid
319111
Expenditure under a single account head which, in aggregate, exceeds Rs. 50,000 paid otherwise than by a crossed bank
11 cheque or crossed bank draft (excluding expenditures not exceeding Rs. 10,000 or on account of freight charges, travel fare, 319112
postage, utilities or payment of taxes, duties, fees, fines or any other statutory obligation)
Salary exceeding Rs. 15,000 per month paid otherwise than by a crossed cheque or direct transfer of the funds to the
12 employee's bank account
319113

13 Capital expenditure 319114

14 Provisions for bad debts, obsolete stocks, etc. 319115

Apportionment of expenditure including profit on debt, financial cost and lease payments relatable or attributable to non-business
15 activities
319116

16 Mark-up on lease financing 319118

17 Accounting pre-commencement expenditure written off 319120

18 Accounting loss on disposal of depreciable assets / intangibles 319121

19 Accounting amortization 319123

20 Accounting depreciation 319124

21 Any other (please specify) 319125

22 Total [Add 1 to 21] to be transferred to Sr-13 of main return 3191 -

Signature _______________________
 Annex - F 2012
Bifurcation of Income/(Loss) from business attributable to
Sales/Receipts Etc. subject to Final Taxation F
Taxpayer Name 0

NTN 0 CNIC (for individual) 0

Subject to Final Subject to Normal

Total Taxation Taxation
Particulars Code Code
Amount (Rs.) Amount (Rs.) Amount (Rs.)

1. Sales (net of brokerage, commission and discount) 3010 3010F

(a) Local sales/supplies - Out of imports (Trading) 30101 30101F -
(b) Local sales/supplies - Others 30102 30102F -
(c) Execution of contracts 30103 30103F -
(d) Export sales 30104 30104F -
(e) Others 30105 30105F -
(f) Sub-total [ Add 1(a) to 1(e)] 30106 - 30106F - -
(g) Selling expenses (Freight outward, etc.) 30107 30107F -
(h) Net ex-factory or F.O.B. sales [ 1(f) minus 1(h)] 30108 - 30108F - -
2. Cost of sales 3011 3011F
(a) Apportioned on the basis of: (i) Actual / identifiable
(ii) Average / proportionate to sales ü
(b) As per income statement 30111 30111F - -
(c) Adjustment of inadmissible costs etc. 30112 30112F
(i) Accounting depreciation 301121 301121F - -
(ii) Accounting amortization 301122 301122F - -
(iii) Others 301123 301123F - -
(iv) 301124 301124F - -
(d) Sub-total [Add c(i) to c(iv)] 30113 - 30113F - -
(e) Revised cost of sales [2(b) minus 2(d)] 30114 - 30114F - -
3. Gross profit/(loss) / other business revenues/receipts 3012 3012F
(a) Gross profit [ 1(h) minus 2(e)] 30121 - 30121F - -
(b) Other business revenues/receipts 30122 30122F
(i) Brokerage and commission 301221 301221F -
(ii) Transport services 301222 301222F -
(iii) Royalty & fee for technical services (non-residents) 301223 301223F -
(iv) Others 301224 301224F -
(v) Other inclusions/exclusions in income 301225 301225F -
(c) Total gross income [ Add 3(a) to 3(b)(v)] 30123 - 30123F - -
4. Administrative, selling, financial expenses etc. 3013 3013F
(a) Apportioned on the basis of: (i) Actual / identifiable
(ii) Average / proportionate to gross income ü
(b) As per income statement 30131 30131F - -
(c) Adjustment of inadmissible expenditures etc. 30132 30132F
(i) Accounting depreciation 301321 301321F - -
(ii) Accounting amortization 301322 301322F - -
(iii) Markup lease financing 301323 301323F - -
(iv) Selling expenses (Freight outward, etc.) 301324 - 301324F - -
(v) Other inadmissible deductions 301325 301325F - -
(vi) Others 301326 301326F - -
(d) Sub-total [Add c(i) to c(vi)] 30133 - 30133F - -
(e) Adjustment of admissible expenditures etc. 30134 30134F
(i) Tax depreciation (Total) 301341 - 301341F - -
(ii) Tax amortization (Total) 301342 - 301342F - -
(iii) Lease rentals 301343 - 301343F - -
(iv) Other admissible deductions 301344 - 301344F - -
(v) Others 301345 - 301345F - -
(f) Sub-total [Add e(i) to e(v)] 30135 - 30135F - -
(g) Net expenditure [ 4(b) minus to 4(d) plus 4(f)] 30136 - 30136F - -
5. Net profit/loss from business [3(c) minus 4(g)] 3014 - 3014F - -

Signature _______________________
 ANNEX-G 2012
Breakup of Expenses
(Separate form should be filled for each business) G
Taxpayer Name 0 NTN 0
Registry

CNIC 0 Tax Year 2012

Business Name 0 RTO/LTU 0
Business Address 0 Business City
Sr. Description Code Amount
Trading Expenses
Manufacturing &

1 Salaries,Wages 311101

2 Electricity 311102

3 Gas 311103

4 Stores/Spares 311106

5 Repair & Maintenance 311108

6 Other Expenses 311118

7 Total [ Add 1 to 6] [Transfer to Sr. 5 of main Return] 31100 0

8 Rent/ Rates/ Taxes 3141

9 Salaries & Wages 3144

10 Travelling/ Conveyance 3145

11 Electricity/ Water/ Gas 3148

Profit & Loss Account Expenses

12 Communication Charges 3154

13 Repairs & Maintenance 3153

14 Stationery/ Office Supplies 3155

15 Advertisement/ Publicity/ Promotion 3157

16 Insurance 3159

17 Professional Charges 3160

18 Profit on Debt (Markup/Interest) 3161

19 Donations 3163

20 Bad Debts Written Off 31821

21 Obsolete Stocks/Stores/Spares Written Off 31822

22 Selling expenses(Freight outwards etc.) 31080

23 Others 31090

24 Total [ Add 8 to 23] [Transfer to Sr. 11 of main Return] 3170 0

Signature _______________________
"