7/31/2019 Individual Income Tax - Appendix

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NAME OF CLIENT: APPENDIXIC NO.(new) :INCOME FOR THE YEAR ENDED 31 DECEMBER 2011 YEAR OF ASSESSMENT 2011SCHEDULE OF INFORMATION/DOCUMENTS REQUIRED

(A) SOURCES OF INCOME

SELF WIFE REMARK

1 Business income attach signed Profit and LossAccount and Balance Sheet2 Partnership income attach signed Profit and Loss

Account and Balance Sheet3 Employment income attach Form EA/EC4 Rental income :-

a. Particular of the property (please use separatesheet for more than 1 property)

b. Gross rental received for the yearc. Deductible expenses:-

- Quit rent- Assessment

- Fire insurance- Bank loan interest (attach bank statement)- Agent commission (attach receipt)- Repair and maintenance (attach receipt)- Others (please specify)

5. Dividend income attach original dividend vouchers

6 Other income attach relevant income statement

(B) CLAIM FOR TAX RELIEFS/REBATES

1 If married or divorced in the year 2011, please state:-

(a) Date of marriage or divorced:(b) Wifes / husbands name:(c) Wifes / husbands new & old I/C no.(d) Wifes / husbands income tax no.:

2 Details of dependent children- for child born in year 2011, attach a copy of birth certificate- for disable child, attach relevant certificate

Child over 18 years old

Name of childDate of

birthName of school/college/university

CourseAttended

Datecommence

course

Annualamount

expended

3 Insurance premium paid for the year 2011 attach copies of premium statement/receipt andif you have just purchased a new insurance policy, attach a copy of the information page ofthe policy.

(a) Life insurance premium & EPF (max RM7,000)

Name of insurance co. Policy no. Self Wife

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7/31/2019 Individual Income Tax - Appendix

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Effective from YA2010, an increased relief amount of RM1,000 (i.e. max RM7,000) isgiven solely in respect of annuity scheme premiums paid to insurance companiescontracted with effect from 1 January 2010. The increased relief amount is alsoapplicable to additional premiums paid on existing annuity schemes where payment

commenced from 1 January 2010.

(b) Children education and medical (self and children) insurance premium (max RM3,000)

Name of insurance co. Policy no. Self Wife

For item 4 to 16, please attach copies of receipts for our verification and ensure original receipts

are available for tax audit purposes.Self Wife

4 Medical expenses for parents attach a copy of birthcertification of yourself/spouse (max RM5,000)

5 Medical expenses for yourself, spouse and children forserious disease attach relevant medical report (maxRM5,000 include RM500 for medical examination)

6 Expenses incurred for a complete medical examination foryourself, spouse or child (max RM500)

7 Expenses incurred for the purchase of supportingequipment for own use, or use by spouse, child or parent

who is disable (max RM5,000)8 Fees expanded on any course of study in any institution inMalaysia recognized by the Malaysian Government foracquiring technical, vocational, industrial, scientific,technological, law, accounting and Islamic financing skills orqualifications at tertiary level or any course of study for adegree at Master or Doctorate level (max RM5,000)

9 Purchase of personal computer (max RM3,000 every 3years once)

10 Purchase of books, journals, magazines and other similarpublications of enhancing knowledge for yourself, spouse orchild (max RM1,000)

11 Purchase of sports equipment (max RM300)12 Broadband subscription fees (max RM500) (only for

YA2010 to 2012)13 Net amount deposit into Skim Pendidikan Nasional for your

children (max RM3,000)14 Zakat / Fitrah payments and /or donations to approved

institution15 Total bi-monthly instalment payments (CP500) to the IRB

attach IRB receipts16 Total STD remitted by your employer to attached a

confirmation of STD payment from your employer (slipjawapan)

17 Details of bank account(a) Name of bank(b) Bank account no.