Income Tax Return for Individuals Taxpayer Ref ITR12

3 5 9 5 6 8 4 1 6 2 Year of Assessment 2 0 2 3
(Income Tax Act, No. 58 of 1962, as amended) No.
Taxpayer Information
Personal Details

Surname K H U M A L O
First Name D U D U Z I L E R U T H
Other Name

Initials Date of Birth ID No.

D R (CCYYMMDD) 1 9 8 3 0 8 2 1 8 3 0 8 2 1 0 3 9 8 0 8 6
Passport Passport Country (e.g. South Africa = ZAF) Passport Issue Date (CCYYMMDD)
No.
Marital Not Married (Single, Divorced, Widow / Widower) Married in Community of Property Married out of Community of Property
Status

Spouse Details

Initials ID No.

Passport Passport Country (e.g. South Africa = ZAF)

No.

Contact Details

Email

Mark here with an "X" if you declare that you do not have an email address IMPORTANT: Any changes made to your contact details on your return will not update your eFiling Security Contact Details. eFiling Security Contact
Details can be maintained via "My Profile" on SARS eFiling, SARS eFiling App or at a SARS branch."
Cell No. 0 7 2 2 5 6 3 8 3 2
Mark here with an "X" if you declare that you do not have a cell phone number

Home
Tel No.

Bus Tel No. 0 8 0 0 0 0 4 7 2 2

Do you confirm that the email and telephone number(s) supplied

Y N
are correct?

ITR12 L Engl FV 2024.20.00 SV 2001 CT 03 NO 3595684162

Y 2023

0000000000 001/006
 Physical Address Details

Unit No. Complex

(if applicable)
Street No. Street / Farm
Name M
Suburb /
District M
City / Town M Country Code Z A
Postal Code 2 0 0 5

Postal Address Details

Mark here with an "X" if same as above or complete your Postal Address. Is your Postal Address a Street Address? Y N

Postal Agency or Other Sub-unit (if applicable) (e.g. Postnet Suite ID)

PO Box Private Bag Other PO Special Number

Service (specify) 2 0 9 4
Post Office N E L S P R U I T Country Code Z A
Postal Code 1 2 0 0
Unit No. Complex
(if applicable)
Street No. Street / Farm
Name
Suburb /
District
City / Town Country Code

Postal Code

ITR12 L Engl FV 2024.20.00 SV 2001 CT 03 NO 3595684162

Y 2023

0000000000 002/006
 Bank Account Holder Declaration
I use South African I use a South African Bank I declare that I have no
bank accounts Account of a 3rd party South African bank account

Reason for No Local / 3rd Party Bank Account

Non-residents without a Deceased Estate Shared Account Income below tax Statutory restrictions
Insolvency / Curatorship threshold / Impractical Minor child
local bank account

Bank Account Details

Bank Account
Status Account No. X X X X X X 6 6 1 5 All changes will be verified before updating your banking profile. SARS will let you know if you need to
come in to a SARS branch with supporting documents. Bank details are required for refunds.
Branch No. 4 7 0 0 1 0 Account Type: Cheque Savings Transmission

Bank Name C A P I T E C B A N K L T D
Branch Name C A P I T E C B A N K C P C
Account Holder
Name (Account
name as registered D U D U Z I L E R U T H K H U M A L O
at bank)
Agreement Statement

Mark here with an ‘X’ if you do declare that this information is true and correct in every respect.

ITR12 L Engl FV 2024.20.00 SV 2001 CT 03 NO 3595684162

Y 2023

0000000000 003/006
 Employee Tax Certificate Information [IRP5 / IT3(a)]

Employer Name C I T Y O F M B O M B E L A
Year of Assessment PAYE
Certificate No. 7 3 5 0 7 9 5 5 8 1 2 0 2 3 0 2 Q W 0 0 0 0 0 1 3 0 0 1 5 8 2 0 2 3 Ref No. 7 3 5 0 7 9 5 5 8 1
(CCYY)

Income Received Income Received continued... Tax Credits and/or Employer / Employee Contribution
Amount Source Code Amount Source Code PAYE R 4102
0 ., 0 0
R Non-Taxable Income PAYE on Lump Sum Benefit
1 9 2 0 3 6 0 1
R R 0 ., 0 0 4115
R 0 3 6 9 6
Employee and Employer UIF Contribution
Gross Employment Income (Taxable)
R R 3 8 ., 4 0 4141
R 1 9 2 0 3 6 9 9 Employer SDL Contribution
R
R 1 9 ., 2 0 4142
R Total Tax, SDL and UIF

R R 5 7 ., 6 0 4149
Deductions / Contributions / Information
Medical Scheme Fees Tax Credit
R 4116
R R 0 ., 0 0
R Additional Medical Scheme Fees Tax Credit
R
R 0 ., 0 0 4120
R
R
R
Reason for Non-Deduction of Employees' Tax
0 2 4150
R
R Voluntary Over Deduction Y N
R
Pay Periods
R
R
Periods in Year of Assessment 1 2 ., 0 0 0 0
R R No. of Periods Worked 1 ., 0 0 0 0
R R Period Employed From (CCYYMMDD) 2 0 2 3 0 2 0 1
R R Period Employed To (CCYYMMDD) 2 0 2 3 0 2 2 8
R Directive Numbers
R
Directive No.
R R
Directive No.
R R
Directive No.
R Total Deductions / Contributions
R Directive No.
R
0 4 4 9 7
Directive No.
ITR12 L Engl FV 2024.20.00 SV 2001 CT 03 NO 3595684162

Y 2023

0000000000 004/006
 Qualifying Criteria for the Deduction of Foreign Taxes Paid or
Proved to be Payable to a Foreign Government of any Country on
any SA Sourced Trading Income (including salary income) -
Rands only, no cents
Did you have a right of recovery other than a right of recovery i. Y N
t.o. a mutual agreement procedure, or any entitlement to carry
back losses arising during any previous year of assessment?
Was this foreign tax amount refunded to you during this year of Y N
assessment?

Taxable income from SA sourced trade income (including salary income) taxed outside
SA (before taking into account any allowable deductions i.t.o. s11F, s18A and
s6quat(1C), as these deductions will be calculated by SARS)
Note: This income must have been declared elsewhere in this return.

ITR12 L Engl FV 2024.20.00 SV 2001 CT 03 NO 3595684162

Y 2023

0000000000 005/006
Declaration

Declaration

I declare that:
• The information furnished in this return is true and correct in every respect; and
• I have disclosed in full the gross amounts of all income accrued to or received by me during the period covered by this xxxxxxxxxxxxxxxxxxxxxxxxx
return; and xxxxxxxxxxxxxxxxxxxxxxxxx
• I have the necessary receipts and records to support all my declarations on this form which I will retain for inspection
purposes.

Please ensure you sign over

the 2 lines of “X”s above
Date For enquiries go to www.sars.gov.za or
(CCYYMMDD) 2 0 2 3 0 7 0 3 call 0800 00 SARS (7277)

ITR12 L Engl FV 2024.20.00 SV 2001 CT 03 NO 3595684162

Y 2023

0000000000 006/006