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WEALTH STATEMENT UNDER SECTION 116 OF THE INCOME TAX ORDINANCE, 2001

Taxpayer's Name CNIC Address Particulars/Description of assets and liabilities (Please read WS Notes for guidance) NTN

WS 1/5
N
Tax Year RTO/LTU Code

2013

A. IMMOVABLE ASSETS 1. Business Capital (indicate name of business)


Sr. 1 2 3 4 5 6 7 8 9 10 Name of Business

821311 Code 82131101 82131102 82131103 82131104 82131105 82131106 82131107 82131108 82131109 82131110

###
Amount (Rs.) -

2.
Sr. 1 2 3 4 5 6 7 8 9 10

Non-Agricultural Property (indicate location, Size/Area & identification)


Type Status Size Land Unit Covered Area Unit District Location

711111 Code 71111101 71111102 71111103 71111104 71111105 71111106 71111107 71111108 71111109 71111110

###
Amount (Rs.) -

3.
Sr. 1 2 3 4 5 6 7 8 9 10

Agricultural Property (indicate location, Size/Area & identification


Size Land Unit Province District Location

711211 Code 71121101 71121102 71121103 71121104 71121105 71121106 71121107 71121108 71121109 71121110

###
Amount (Rs.) -

B. MOVEABLE ASSETS

4.
1 2 3 4 5 6 7 8 9

Business Capital (Except immovable portion)


Name of Business

Sr.

821312 Code 82131201 82131202 82131203 82131204 82131205 82131206 82131207 82131208 82131209 82131210

###
Amount (Rs.) -

10

5.
Sr. 1 2 3 4 5 6 7 8 9

Agricultural Moveable Property (Tractor, Trolley, Loader, Planter, Harvester, Thrasher, Driller & other Agricultural Equipments etc. & Live Stock)

712111 Code 71211101 71211102 71211103 71211104 71211105 71211106 71211107 71211108 71211109

###
Amount (Rs.) -

Property Name

Quantity

Description

10

71211110

WEALTH STATEMENT UNDER SECTION 116 OF THE INCOME TAX ORDINANCE, 2001
Taxpayer's Name CNIC Address Particulars/Description of assets and liabilities (Please read WS Notes for guidance) NTN

WS 2/5
N
Tax Year RTO/LTU Code 712611 Code 71261101 71261102 71261103 71261104 71261105 71261106 71261107 71261108 71261109 71261110 ### Amount (Rs.) -

2013

6.
Sr. 1 2 3 4 5 6 7 8 9 10

Investments (Specify stocks, shares, debentures, unit certificates, other certificates, deposits and certificates of National Saving Schemes,mortgages, loans, advances, etc.) Invesments

Description

7.
Sr. 1 2 3 4 5 6 7 8 9 10

Loans and Advances, etc.


Bebtor Name

712641 Code 71264101 71264102 71264103 71264104 71264105 71264106 71264107 71264108 71264109 71264110

###
Amount (Rs.) -

8.
Sr. 1 2 3 4 5 6 7 8 9 10

Motor vehicles (Indicate make, model and registration number)


Registration No. Make Model with Year Engine Capacity (CC)

712211 Code 71221101 71221102 71221103 71221104 71221105 71221106 71221107 71221108 71221109 71221110

###
Amount (Rs.) -

9.
Sr. 1 2 3 4 5 6 7 8 9 10

Jewellery (Indicate description weight and value)


Description and weight with unit of measure (e.g 10 Tolas)

712411 Code 71241101 71241102 71241103 71241104 71241105 71241106 71241107 71241108 71241109 71241110 712311 Code 71231101 71231102 71231103 71231104 71231105 71231106 71231107 71231108 71231109 71231110

###
Amount (Rs.) -

10. Furniture and Fittings - Residence


Sr. 1 2 3 4 5 6 7 8 9 10 Description

###
Amount (Rs.) -

WEALTH STATEMENT UNDER SECTION 116 OF THE INCOME TAX ORDINANCE, 2001
Taxpayer's Name CNIC Address Particulars/Description of assets and liabilities (Please read WS Notes for guidance) NTN

WS 3/5
N
Tax Year RTO/LTU Code 7128 712811 712711 Code 71271101 71271102 71271103 71271104 71271105 71271106 71271107 71271108 71271109 71271110 7126 Code 71267101 71267102 71267103 71267104 71267105 71267106 71267107 71267108 71267109 71267110 Amount (Rs.) -

2013

11.

Cash & Bank Balances (a) (b) Non-business cash in hand


Non-business bank balances, etc. in current/ deposit/ savings accounts or any other deposit)

###

Sr. 1 2 3 4 5 6 7 8 9 10

Account No. Country

Bank Name

City Name Br. Code

Branch Name

12. Any Other Assets


Sr. 1 2 3 4 5 6 7 8 9 10 Description

###
Amount (Rs.) -

13.
Sr. 1 2 3 4 5 6 7 8 9 10

Assets, if any, standing in the name of spouse*, minor children & other dependents Description

713111 Code 71311101 71311102 71311103 71311104 71311105 71311106 71311107 71311108 71311109 71311110

###
Amount (Rs.) -

14. Total Assets [ Sum(1 to 13 ] 15. Liabilities (including mortgages, loans, overdrafts, advances, borrowings,
amounts due under hire purchase agreement )
Liabilities Sr. 1 2 3 4 5 6 7 8 9 10

719999 ###

8213 Code 72111101 72111102 72111103 72111104 72111105 72111106 72111107 72111108 72111109 72111110

###
Amount (Rs.) -

Description

16. 17. 18. 19.

Total Liabilities Net Wealth of the current year [14 minus 16] Annual personal expenses ( To be reconciled with Annex D / IT-4) Number of family members and dependents

729999 799999 749999 740000

### ###

Adults

Minors

WEALTH STATEMENT UNDER SECTION 116 OF THE INCOME TAX ORDINANCE, 2001
Taxpayer's Name CNIC Address Particulars/Description of assets and liabilities (Please read WS Notes for guidance) NTN

WS 4/5
N
Tax Year RTO/LTU Code 714111 Code 71411101 71411102 71411103 71411104 71411105 71411106 71411107 71411108 71411109 71411110

2013

20.
Sr. 1 2 3 4 5 6 7 8 9 10

Assets, if any, transferred to any person


Description

###
Amount (Rs.) -

Verification
I, _______________________________________________, holder of CNIC No. ______________________________ in my capacity as Self/ Representative* of the taxpayer named above, do hereby solemnly declare that to the best of my knowledge and belief the information given in this statement of the assets and liabilities of myself, my spouse or spouses, minor children and other dependents as on _______________ and of my personal expenditure for the year ended ________ are correct and complete in accordance with the provisions of the Income Tax Ordinance, 2001, Income Tax Rules, 2002 and Income Support Levy Act, 2013.

Date (dd/mm/yyyy): * The spouse who has not filed return of income along with wealth statement independently

Signature

WS 1/5 2013

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

WS 2/5 2013

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

WS 3/5 2013

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

unt (Rs.) -

WS 4/5 2013

unt (Rs.) -

WEALTH RECONCILIATION STATEMENT N


Taxpayer's Name CNIC Address NTN Tax Year RTO/LTU

WS 5/5

2013
Amount (Rs.)

Particulars
1 2 3 4 Net assets as on 30-06-2013 Net assets as on 30-06-2012 Increase/Decrease [1 - 2] Income a) Income declared for the Tax Year - 2013 b) Exempt income including agriculture income c) Others i) ii) iii) iv) v) 5 Expenditures a) Personal expenditures b) Other expenditures i) ii) iii) iv) v) 6 Increase/ Decrease in wealth [4 - 5]

Code

Date :

Signature:

"

WEALTH STATEMENT UNDER SECTION 116 OF THE INCOME TAX ORDINANCE, 2001 (Notes on reverse) Notes
1. If the space provided in the form is found to be inadequate, additional sheet(s) may be used. 2. All assets should be valued at cost. 3. If any exact figure can not be inserted, an estimate should be made, mark it clearly "ESTIMATE". If balance sheet in respect of any business has been submitted to the Department, the entry of "Business Capital" should 4. (a) consist of the net balance on capital, current and loan accounts as shown in those Balance Sheets on the specified date, if such net amount is a credit balance. Where no Balance Sheet has been submitted, the assessed should list, on a separate sheet of paper attached to this form, (b) the assets and liabilities of the business on the specified date. The excess of assets listed, should be entered as "Business Capital". (c) If the net balance at (a) above is a debit balance, it should be included in liabilities. 5. Agricultural equipment, such as irrigation pumps and tube-wells etc., should be detailed at cost with description. 6. Give details of stocks, shares and debentures, e.g., number, face value, name of the company and type. 7. Give details of assets of the spouse, minor children and other dependents and state whether such asset was transferred directly or indirectly to the spouse or minor children or other dependents or was acquired by them with funds provided by you. 8. In the case of assets acquired under a Hire Purchase agreement, the total price should be shown under the appropriate head in the assets and the balance amount due should be shown under the liabilities. 9. Where the statement is being filed for the first time or covers more than one tax year, separate re-conciliation of the increase/ (decrease) in wealth and of the sources and applications should be provided for each year.
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