Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

INDIAN INCOME TAX RETURN

FORM [For Individuals, HUFs and Firms (other than LLP) being a resident having total income upto Rs.50 lakh and Assessment
ITR1 having income from business and profession which is computed under sections 44AD, 44ADA or 44AE][Not for Year
SAHAJ an individual who is either Director in a company or has invested in unlisted equity shares or if income-tax is 2023 - 24
deferred on ESOP or has agricultural income more than Rs.5000](Please refer instructions for eligibility)

PART A GENERAL INFORMATION

(A1) PAN (A2) First Name (A3) Last Name

(A2a) Middle Name
AVYPD9442Q DEBABRATA DAKUA
(A5) Aadhaar Number(12 digits)/Aadhaar Enrolment Id(28 digits) (if
(A4) Date of Birth (A6) Mobile No
eligible for Aadhaar No.)
08/02/1985 +91 9437226267
6xxx xxxx 5418
(A9) Name of
(A8) Flat/Door/Block No. (A10) Road/Street/Post Office,
(A7) Email Address Premises/Building/Village
DISTRICT MEDICAL Area/Locality
rnb2661974@gmail.com DISTRICT MEDICAL
NABRANGPUR Agnipur B.O Agnipur
NABRANGPUR
(A11) Town/City/District (A12) State (A13) Country/Region (A14) PIN Code/ZIP Code
NABARANGAPUR 24-Odisha 91-INDIA 764059

(A17) Nature of employment State Government

(A15)(a) Filed u/s (Tick)[Please see instruction] 139(4)-After due date

(A16) Or Filed in response to notice u/s

(A18) If revised/defective then enter Receipt No. and Date of filing of

original return (DD/MM/YYYY)
(A19) If filed in response to notice u/s 139(9)/142(1)/148/153C or order u/s
119(2)(b)- enter Unique Number/ Document Identification Number (DIN) &
Date of such Notice or Order
(A20) Are you opting for new tax regime u/s 115BAC?
Yes No
(A21) Are you filing return of income under Seventh proviso to section 139(1) but otherwise not required to furnish return of income? - (Tick)
Yes No
If yes, please furnish following information [Note: To be filled only if a person is not required to furnish a return of income under section 139(1) but
filing return of income due to fulfilling one or more conditions mentioned in the seventh proviso to section 139(1)]
(i) Have you incurred expenditure of an amount or aggregate of amount exceeding Rs. 2 lakhs for travel to a
foreign country for yourself or for any other person? 0
Yes No
(ii) Have you incurred expenditure of amount or aggregate of amount exceeding Rs. 1 lakh on consumption of
electricity during the previous year? 0
Yes No
(iv) Are you required to file a return as per other conditions prescribed under clause (iv) of seventh proviso to section 139(1) (If yes, please select the
relevant condition from the drop down menu)
Yes No

Sl No. Nature Amount

(1) (2) (3)

PART B GROSS TOTAL INCOME

B1 i Gross Salary (ia + ib + ic + id + ie) i 11,66,985

a Salary as per section 17(1) ia 11,66,985

b Value of perquisites as per section 17(2) ib 0

c Profit in lieu of salary as per section 17(3) ic 0

Income from retirement benefit account maintained in a notified country u/s

d id 0
89A

Income from retirement benefit account maintained in a country other than

e ie 0
notified country u/s 89A
Less allowances to the extent exempt u/s 10 [Ensure that it is included in salary income u/s
ii ii 1,01,600
17(1)/17(2)/17(3)]

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

Sl.
Nature of Exempt Allowances Description ( If Any Other selected) Total Amount
No.

(1) (2) (3) (4)

Sec 10(14)(i)- Prescribed Allowances or

benefits (not in a nature of perquisite)
specifically granted to meet expenses
1 wholly, necessarily and exclusively and to 15000
the extent actually incurred, in
performance of duties of office or
employment
Sec 10(14)(ii) -Prescribed Allowances or
benefits granted to meet personal
2 expenses in performance of duties of 1600
office or employment or to compensate
him for increased cost of living.
Sec 10(13A)-Allowance to meet
3 60000
expenditure incurred on house rent
Sec 10(5)-Leave Travel
4 25000
concession/assistance

iia Less : Income claimed for relief from taxation u/s 89A iia 0

iii Net Salary (i - ii - iia) iii 10,65,385

iv Deductions u/s 16 (iva + ivb + ivc) iv 55,000

a Standard deduction u/s 16(ia) iva 50,000

b Entertainment allowance u/s 16(ii) ivb 5,000

c Professional tax u/s 16(iii) ivc 0

v Income chargeable under the head 'Salaries' (iii - iv) B1 10,10,385

B2 Type Of House Property B2

i Gross rent received/ receivable/ lettable value during the year i 0

ii Tax paid to local authorities ii 0

iii Annual Value (i - ii) iii 0

iv 30% of Annual Value iv 0

v Interest payable on borrowed capital v 0

vi Arrears/Unrealised rent received during the year less 30% vi 0

Income chargeable under the head 'House Property' (iii - iv - v) + vi (If loss, put the figure in
vii B2 0
negative)

B3 Income from Other Sources B3 4,137

Sl.
Nature of Income Description ( If Any Other selected) Total Amount
No.

(1) (2) (3) (4)

1 Interest from Saving Account 4,137

Quarterly breakup of Dividend Income Quarterly breakup of Income from retirement benefit
account maintained in a notified country u/s 89A
(taxable portion)

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

(i) Up to 15-Jun-2022 0 (i) Up to 15-Jun-2022 0

From 16-Jun-2022 to From 16-Jun-2022 to 15-

(ii) 0 (ii) 0
15-Sep-2022 Sep-2022
From 16-Sep-2022 to From 16-Sep-2022 to
(iii) 0 (iii) 0
15-Dec-2022 15-Dec-2022
From 16-Dec-2022 to From 16-Dec-2022 to
(iv) 0 (iv) 0
15-Mar-2023 15-Mar-2023
From 16-Mar-2023 to From 16-Mar-2023 to
(v) 0 (v) 0
31-Mar-2023 31-Mar-2023

Less: Income claimed for relief from taxation u/s 89A 0

Less: Deduction u/s 57(iia) (in case of family pension only) 0

Gross Total Income (B1+B2+B3) (If loss, put the figure in negative) Note: To avail the benefit
B4 B4 10,14,522
of carry forward and set off of loss, please use ITR-2

PART C - DEDUCTIONS AND TAXABLE TOTAL INCOME

Sl.No. Section Amount System Calculated

80C - Life insurance premia, deferred annuity, contributions to provident 95,000

C1 95,000
fund, subscription to certain equity shares or debentures, etc.

C2 80CCC - Payment in respect Pension Fund 0 0

C3 80CCD(1) - Contribution to pension scheme of Central Government 0 0

C4 80CCD(1B) -Contribution to pension scheme of Central Government 0 0

80CCD(2) - Contribution to pension scheme of Central Government by

C5 employer 55,000 55,000

C6 80D - Deduction in respect of health insurance premia 20,000 20,000

80DD - Maintenance including medical treatment of a dependent who is a 0

C7 0
person with disability -

0
C8 80DDB - Medical treatment of specified disease - 0

C9 80E - Interest on loan taken for higher education 0 0

C10 80EE - Interest on loan taken for residential house property 0 0

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

80EEA - Deduction in respect of interest on loan taken for certain house

C11 0 0
property

C12 80EEB - Deduction in respect of purchase of electric vehicle 0 0

80G - Donations to certain funds, charitable institutions, etc (Please fill

C13 0 0
80G schedule.This field is auto-populated from schedule 80G.)

C14 80GG - Rent paid (Please submit form 10BA to claim deduction) 0 0

80GGA - Certain donations for scientific research or rural development

C15 0 0
(Please fill 80GGA Schedule. This field is autopopulated from schedule.)

C16 80GGC - Donation to Political party 0 0

C17 80TTA - Interest on deposits in saving bank Accounts 0 0

C18 80TTB- Interest on deposits in case of senior citizens. 0 0

C19 80U - In case of a person with disability - 0 0

C20 80CCH- Contribution to Agnipath Scheme 0 0

C21 Total deductions (Add items C1 to C18) 1,70,000 1,70,000

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

Total Income 8,44,520

EXEMPT INCOME (FOR REPORTING PURPOSES)

Sl.
Nature of Income Description ( If Any Other selected) Total Amount
No.

(1) (2) (3) (4)

Total 0

PART D - COMPUTATION OF TAX PAYABLE

D1 Tax payable on total income D1 81,404

D2 Rebate u/s 87A D2 0

D3 Tax after rebate D3 81,404

D4 Health and education Cess @4% on D3 D4 3,256

D5 Total Tax and Cess D5 84,660

D6 Relief u/s 89 (Please ensure to submit Form 10E to claim this relief) D6 0

D7 Interest u/s 234A D7 0

D8 Interest u/s 234B D8 0

D9 Interest u/s 234C D9 0

D10 Fee u/s 234F D10 5,000

D11 Total Tax, Fee and Interest (D5 + D7 + D8 + D9 + D10 - D6) D11 89,660

D12 Total Taxes Paid D12 1,00,922

D13 Amount payable (D11-D12) (if D11>D12) D13 0

D14 Refund (D12 - D11) (if D12 > D11) D14 11,260

PART E - OTHER INFORMATION DETAILS OF ALL BANK ACCOUNTS HELD IN INDIA AT ANY TIME DURING THE PREVIOUS YEAR
(EXCLUDING DORMANT ACCOUNTS)
Sl. Select Account for Refund
IFS Code of the Bank Name of the Bank Account Number
No. Credit

(1) (2) (3) (4) (5)

1 SBIN0002064 STATE BANK OF INDIA 30711697680

SCHEDULE 80D

1 Whether you or any of your family member (excluding parents) is a senior citizen? No

(a) Self & Family 5,000

(i) Health Insurance 5,000

(ii) Preventive Health Checkup

0

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

(b) Self & Family including Senior Citizen 0

(i) Health Insurance 0

(ii) Preventive Health Checkup 0

Medical Expenditure (This deduction to be claimed on which health insurance is

(iii) 0
not claimed at (i) above)

2 Whether any one of your parents is a senior citizen Yes

(a) Parents 0

(i) Health Insurance 0

(ii) Preventive Health Checkup 0

(b) Parents including Senior Citizen 15,000

(i) Health Insurance 5,000

(ii) Preventive Health Checkup 0

Medical Expenditure (This deduction can be claimed on which health insurance is

(iii) 10,000
not claimed at (i) above)

3 Eligible Amount of Deduction 20,000

SCHEDULE 80G DETAILS OF DONATIONS ENTITLED FOR DEDUCTION UNDER SECTION 80G

A. DONATIONS ENTITLED FOR 100% DEDUCTION WITHOUT QUALIFYING LIMIT, (WHERE ANY ROW IS FILLED BY THE USER, ALL THE
FIELDS IN THAT ROW SHOULD BECOME MANDATORY)

City or Amount of donation Eligible

Sl. Name of PAN of the
Address Town or State code Pin code Amount of
No. the Donee Donee Donation in Donation in Total
District Donation
cash other mode donation

(1) (2) (3) (4) (5) (6) (7) (9) (10) (11) (12)

Total A 0 0 0 0

B. DONATIONS ENTITLED FOR 50% DEDUCTION WITHOUT QUALIFYING LIMIT (WHERE ANY ROW IS FILLED BY THE USER, ALL THE
FIELDS IN THAT ROW SHOULD BECOME MANDATORY)

City or Amount of donation Eligible

Sl. Name of Town or PAN of the Amount of
Address State code Pin code
No. the Donee District Donee Donation in Donation in Total Donation
cash other mode donation

(1) (2) (3) (4) (5) (6) (7) (9) (10) (11) (12)

Total B 0 0 0 0

C. DONATIONS ENTITLED FOR 100% DEDUCTION SUBJECT TO QUALIFYING LIMIT (WHERE ANY ROW IS FILLED BY THE USER, ALL THE
FIELDS IN THAT ROW SHOULD BECOME MANDATORY)

City or Amount of donation Eligible

Sl. Name of PAN of the
Address Town or State code Pin code Amount of
No. the Donee Donee Donation in Donation in Total
District Donation
cash other mode donation

(1) (2) (3) (4) (5) (6) (7) (9) (10) (11) (12)

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

Total C 0 0 0 0

D. DONATIONS ENTITLED FOR 50% DEDUCTION SUBJECT TO QUALIFYING LIMIT (WHERE ANY ROW IS FILLED BY THE USER, ALL THE
FIELDS IN THAT ROW SHOULD BECOME MANDATORY)

Amount of donation
ARN
City or Eligible
Sl. Name of Address Pin code PAN of the (Donation Donation
Town or State code Donation Total Amount of
No. the Donee Donee Reference in other
District in cash donation Donation
Number) mode

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

Total D 0 0 0 0

E. Total Amount of Donations (A + B + C + D) 0 0 0 0

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

SCHEDULE 80GGA DETAILS OF DONATIONS FOR SCIENTIFIC RESEARCH OR RURAL DEVELOPMENT

Relevant
Clause Amount of Donation
City or Eligible
Sl. under Name of PAN of the
Address Town or State Code Pin code Donation Amount of
No. which the Donee Donee Donation Total
District in other Donation
deduction in Cash Donation
is claimed mode

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

Total 0 0 0 0

TAX PAYMENTS
Sl.
BSR Code Date of Deposit (DD/MM/YYYY) Serial Number of Challan Tax paid
No.

(1) (2) (3) (4) (5)

Total 0

SCHEDULE TDS1 - DETAILS OF TAX DEDUCTED AT SOURCE FROM SALARY [AS PER FORM 16 ISSUED BY EMPLOYER(S)]
Sl. Income chargeable under
TAN of the Deductor Name of the Deductor Total Tax Deducted
No. salaries

(1) (2) (3) (4) (5)

1 BBNA00443C A D M O MEDICAL 11,66,985 77,000

Total 77,000

SCHEDULE TDS2 - DETAILS OF TAX DEDUCTED AT SOURCE FROM INCOME OTHER THAN SALARY [AS PER FORM 16A ISSUED BY
DEDUCTOR(S)]
Gross receipt which
Sl. Name of the Year of tax TDS Credit out of
TAN of the Deductor is subject to tax Tax Deducted
No. Deductor deduction (5)claimed this year
deduction

(1) (2) (3) (4) (5) (6) (7)

LIFE INSURANCE
1 BBNL00005F CORPORATION OF 38,720 2022 3,872 3,872
INDIA
APOLLO HOSPITALS
2 VPNA00671G 14,873 2022 1,487 1,487
ENTERPRISE LTD

Total 5,359

SCHEDULE TDS3 DETAILS OF TAX DEDUCTED AT SOURCE (AS PER FORM 16C FURNISHED BY THE PAYER(S))
Gross receipt TDS Credit out
Sl. PAN of the Aadhaar Number Name of the Year of tax
which is subject Tax Deducted of (6) claimed
No. Tenant of the Tenant Tenant deduction
to tax deduction this year

(1) (2) (3) (4) (5) (6) (7) (8)

Total 0

SCHEDULE TCS
Tax Collection Name of the Gross payment Year of tax
Sl. TCS Credit out of (5)
Account Number of which is subject to collection Tax Collected
No. Collector claimed this year
the Collector tax collection

(1) (2) (3) (4) (5) (6) (7)

HINDUSTAN SALES
1 BBNH00128C 18,56,300 2022 18,563 18,563
PRIVATE LIMITED

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”
Acknowledgement Number : 600928080311223 Date of Filing : 31-Dec-2023*

Total 18,563

VERIFICATION

I, DEBABRATA DAKUA son/ daughter of NIRANJAN DAKUA solemnly declare that to the best of my knowledge and belief, the information given in
the return is correct and complete and is in accordance with the provisions of the Income-tax Act, 1961. I further declare that I am making this return
in my capacity as Self and I am also competent to make this return and verify it. I am holding permanent account number AVYPD9442Q

Place: 202.168.86.44

Date: 31-Dec-2023

If the return has been prepared by a Tax Return Preparer (TRP) give further details below:

Identification No. of TRP Name of TRP Counter Signature of TRP

If TRP is entitled for any reimbursement from the Government, amount thereof 0

*If the return is verified after 30 days of transmission of return data electronically, then date of verification will be considered as date of filing the
return (Notification No.05 of 2022 dated 29-07-2022 issued by the DGIT (Systems), CBDT).”