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PART A – PERSONAL PARTICULARS

Name in full (Surname first) DOB Phone Email TIN (If you already have) Address Occupation Industry Sector (Please see attched industry sector list) Name of Employer (If any) Address of business or Employment City

About your Spouse

Marital status If Married, Name of Spouse Occupation Employer or Business Name

Nationality Date of Arrival in Nigeria

PART B

INCOME DECLARATION FOR YEAR ENDED 31ST DECEMBER,

(Complete each section. Write “none” if a section does not apply to you)

Source of Income	₦	K	Action
Aggregate Income from all sources (AI)	0
		Add More..

DEDUCTIONS CLAIMED FROM INCOME OF THE YEAR ENDED, 31ST DECEMBER,

Contributions or involvement in the following, enjoy relief at various allowable rates; NHIS – 5%, NHF – 2.5%, Pension contribution – 8%, Life assurance premium – 100%, Gratuity – 100%. Other deductions that may be claimed by approaching the ESIRB include; Widows and orphans Pension Ordinance, NISTF, Provident or other societies fund. Please list the deductions claimed (if any) and the amounts at applicable rates.	₦	K	Action
Total Deduction due to Tax exempt items (TEI)	0
		Add More..

Part C: Compute your Consolidated Relief Allowance (CRA)

Tax Reliefs	Tax Amount
Higher of N200,000 p.a or 1% of aggregate income	₦ 0.00
20% of income	₦ 0.00
CRA	₦ 0.00

Part D: Compute Chargeable Income (CI)

Source of Income	₦	K
Annual Income (AI)
Cummulative Relief Allownace (CRA)
Total Deduction Exempt Items (TEI)
Chargeable Income (CI) = AI – CRA - TEI

Part E: Apply Income tax rates to corresponding bands while deducting the amounts from the CI

Bands and Rates	₦	K
Subtract first N300,000 at 7%	-
Subtract next N300,000 at 11%	-
Subtract next N500,000 at 15%	-
Subtract next N500,000 at 19%	-
Subtract next 1,600,000 at 21%	-
Calculate remaining balance of the CI at 24%	-
Annual Payable Tax (Total)	-

Note: Your minimum annual tax is 1% of your aggregate income, even If your tax computation results in negative chargeable value.

₦	K
-

Declaration (Which must be completed and signed)

I, hereby declare that the information supplied in this form is a true and correct statement of the amount of my income from all sources. Given under my hand, this ______________day of _________________20 _____________

__________________________________________ Signature of person making this Return

________________________ Signature of Received

For Office Use

General Instructions:
1.	Fields marked with asterisk (*) are mandatory.
2.	All amounts are in Naira.
3.	It is a good practice to save your work frequently. Please use SAVE AS DRAFT option.
4.	In Forms wherever information is captured in tables
	(a) Adding new Row: Click ADD button to add a new row and enter values in the field provided.
	(b) Deleting Row: Select the row to delete from the list and click DELETE ROW button.
5.	Please verify the Form before you submit.

PART A – PERSONAL PARTICULARS

About your Spouse

PART B

INCOME DECLARATION FOR YEAR ENDED 31ST DECEMBER,

Part C: Compute your Consolidated Relief Allowance (CRA)

Part D: Compute Chargeable Income (CI)

Part E: Apply Income tax rates to corresponding bands while deducting the amounts from the CI

Declaration (Which must be completed and signed)

Bill Reference Details:

Credit Bank Details:

Reference not yet paid and need to go bank to pay

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