Income Tax Return Form A

Tax Year Information

Returns for Income Tax Year

Applicable During Year Ended 31st December

PART A: PERSONAL INFORMATION

Surname (in CAPITALS)

Surname at Birth (if different)

First Name

Middle Name

Title

Marital Status

Date of Birth

Nationality

Current Residential Address (not P.O. Box)

Mobile No. 1

Mobile No. 2

Email Address

Contact Address

RC No.

TIN

JTB TIN

BVN

Source of Income

Occupation

Name of Business

Address of Business or Employer (not P.O. Box)

Business Sector

Passport PhotographMax 5MB, JPG/PNG only

Spouse Details

Spouse Name

Spouse Occupation

Spouse Employer

Business or Employer Address

PART B: STATEMENT OF INCOME FOR THE YEAR

A) EARNED INCOME

i. Employment (Salary, Allowances, Commission etc.)

ii. Trade, Business, Profession, Vocation etc.

iii. Pension, Annuity, Gratuity

iv. Income from outside Nigeria

B) INVESTMENT INCOME

v. Dividends

vi. Interest

vii. Rents

viii. Other Income

Total Earned Income (A):
₦0.00

Total Investment Income (B):
₦0.00

TOTAL INCOME (A + B):
₦0.00

CHILDREN/DEPENDANTS INFORMATION

Full Name

Date of Birth

Educational Institution

Child Income (₦)

PART E: (b) Vehicles Owned

Date of Purchase

Cost (₦)

Brand

Model

Year

PART C: TENANCY DETAILS (Complete if Tenant)

(i) Residential Address

Residential Address

Landlord's Name

Location of Premises

Current Rent Payable (₦)

1st Year of Rentage

Part of Rent Paid by Employer (₦)

(ii) Business Address

Business Address

Landlord's Name

Landlord's Address

Landlord's Phone

Location of Premises

PART D: RENTAL INCOME DISCLOSURE (Complete if Landlord)

Tenant Name	Tenant Phone	Property Description	Location	Units	Annual Rental Income (₦)	Years in Use	Action

PART E: (a) Domestic Servants

Name	Residential Address	Amount Paid (₦)	Telephone

PART E: (c) Tangible Immoveable Properties

Property Type	Location	Date Completed	Cost of Produce (₦)	Cost of Land (₦)	Cost of Construction (₦)	Action

PART F: LIFE ASSURANCE, NHIS AND PENSION CONTRIBUTIONS

Company Name	Policy Type	Life Assured	Capital Sum (₦)	Premium Paid (₦)	Payment Date	Action

DECLARATION

PENALTY FOR DEFAULT: Making false statements or wilful refusal to pay accurate tax will attract fines or imprisonment in accordance with applicable Nigerian law.

I hereby declare that the information supplied in this form is, to the best of my knowledge, a true and complete statement of my income from all sources. I understand I may face financial penalties and prosecution for providing false information.

Taxpayer Identity Verification

CROSS RIVER STATE INTERNAL REVENUE SERVICE — INCOME TAX RETURN FORM A