FORM 4-A

[See Rule 19(3-A)]

I. Return to be furnished by an enrolled person / employee under section 10(1) of the Karnataka Tax on Professions, Trades, Callings and Employments Act, 1976.

1. Return for the year ending on

2. Name of the enrolled person

3. Full address and Telephone No.

4. Enrollment Certificate No.

5. Profession, Trade, etc. (specify) :

6. Amount of tax payable / paid vide Ch. No.___________ Date_____________ on ________ Bank / Cash Receipt No._______________ Date_____________

7.

II. Details of exemption claimed in respect of any partners who have paid tax in other firms or exempt senior citizens or in any other capacity:

1. Name of the person

2. Full address and Telephone No.

3. Class of enrolled person (whether individual, partnership firm, company and others, etc.) (Specify):

4. Enrollment Certificate No.

5. VAT No.

6. Payment details, cheque No./ Cash receipt No.

7. Office in which the payment is made.

I, ........................certify that the information furnished above is true to the best of my knowledge and belief.