FORM NO 4A
[See chapter XII-C of the Income-tax Act, 1961 and rule 11EE of the Income-tax Rules]
Statement under the simplified procedure
HEAD: 0021 INCOME-TAX – SIMPLIFIED PROCEDURE

1.	NAME (SURNAME FIRST) (IN BLOCK LETTERS)	

	

2.		FINANCIAL YEAR                              [	1	9	9	6	----	1	9	9	7	]	
		
3.		RESIDENTIAL ADDRESS	

	

	

	

	

4.		BUSINESS ADDRESS (IN BLOCK LETTERS)	

	

	

	

	

	
5.		STATUS*	INDIVIDUAL			HINDU UNDIVIDED  FAMILY					
		
6.		NATURE OF BUSINESS OR VOCATION*	
													
RETAIL TRADE			EATING PLACE			TAILORING			HAIR CUTTING				
													
TYPING			PHOTOCOPYING			REPAIR WORK			WASHING CLOTHS				

	
OPERATING/HIRING/LEASING TRANSPORT VEHICLE																	

	
ANY OTHER VOCATION - SPECIFY																								

	
7.		DEEMED INCOME FROM BUSINESS OR VACATION :							[	Rs.	4	9	3	3	0	]	

	
8.		INCOME FROM SOURCES OTHER THAN BUSINESS OR 							Rs.					
	VOCATION CHARGEABLE TO TAX [NOT EXCEEDING Rs. 5,0000										

	
9.		DIDUCTION UNDER SECTION 80L in respect of income from dividend ,					Rs.					
	Interest on bank deposits and on other specified deposits and such securities 											
	[NOT EXCEEDING Rs. 5,000]											

	
10.		NET INCOME FROM SOURCES OTHER THAN BUSINESS OR 					Rs.					
	VOCATION [8 MINUS 9]											
11.		TAX PAYABLE [Rs. 1,400 plus 20% OF AMOUNT AT (10)]					Rs.					

Vrification
[I, ................(name in full and block letters) **son/daughter/wife/karta/member of Hindu undivided family hereby declare that what is stated is true to the best of my knowledge and belief.
I further declare that I have not been assessed to income-tax for any assessment year commencing on or before 1st April, 1992.
I also hereby declare that my income during the financial year 1996-97 from the business or vocation mentioned at item 6 does not exceed forty-nine thousand three hundred and thirty rupees and I do not have any income exceeding Rs. 5,000 from sources other than business or vocation mentioned above.

Date ........................						.........................................................
Place .......................							(Name and signature)
Note:
*Tick the one which is applicable.
**Strike out whichever is not applicable.
Paid in cash/by cheque/draft No ........... dated...........
Rupee ................................ Rs. .................................
            [in words]                         [in figures]
into ................................... Branch of ........................
                                                 [Name of the bank]

....................................................................................
Signature of the person making the payment	FOR USE INTHE RECEIVING BANK	
	RECEIVED PAYMENT

Serial No. In Scroll 
Cheque/draft tendered on 
Cheque/draft realised on

Signature of chashier	
	STAMP OF THE BANK]