gOvERNMENT OF THE REPubLIC OF TRINIDAD AND TObAgO Ministry of Finance, Inland Revenue Division

indiViduAL income tAx return For 2012 emoLument income onLY

V2-12440emoP01

NAME CHANgE ADDRESS CHANgE identiFicAtion section

2012
Form 440 emo

FIRST NAME

MIDDLE NAME

Spouses bIR File No.

PRESENT ADDRESS (Street no. and name)

Date of birth (DD MM YYYY)

CITY OR TOWN

COuNTRY

National Identication No.

MAILINg ADDRESS IF DIFFERENT FROM AbOvE (Street no. and name)

Drivers Permit No.

CITY OR TOWN

COuNTRY

PIN No. (Electronic birth Certicate No.)

OCCuPATION OR PROFESSION

Please tick the appropriate box Resident Male Female

E-MAIL ADDRESS

TELEPHONE/MObILE CONTACT # Non-Resident

tAx comPutAtion section income 1 2 3 4 5 6 7 8 9 Income from Employment (government and Non-government) as per TD4 enclosed Retirement Severance benet - See Instructions 13 and 31 Pensions from sources within/outside T&T totAL emoLument income (SuM OF LINES 1 TO 3) Less travelling expenses - See Instruction 12 net emPLoYment income (LINE 4 MINuS LINE 5) gross Amount Received on Cancellation of Approved Deferred Annuity/Pension Plan - See Instruction 15 Employers contribution to Approved Deferred Annuity/Pension Plan (Taxable benet) complete schedule A totAL income (SuM of LINES 6 to 8) 1 2 3 4 5 6 7 8 9 to nearest dollar, omit cents/commas

deductions 10 11 12 13 14 15 16 17 18 19 Tertiary Education Expenses (Limited to $60,000 per household) - See Instruction 21 First-Time Acquisition of House in respect of Owner Occupied Property (Limited to $18,000) - See Instruction 22 Covenanted Donations (Limited to 15% of Line 9) totAL net income (Line 9 minus sum oF Lines 10 - 12) Deduct Personal Allowance - $60,000 - See Instruction 24 AssessABLe income (Line 13 minus Line 14) Approved Pension Plan/Scheme/Deferred Annuity Plan - See Instruction 25 Contributions to Widows and Orphans Fund - See Instruction 25 National Insurance Payments - 70% Allowable - See Instruction 25 sum oF Lines 16 to 18 (Limited to $30,000) 10 11 12 13 14 15 16 17 18 19

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2012
Form 440 emo
Bir no.

deductions contd 20 21 22 23 24 25 26 Employers NIS Contributions paid for domestic workers - See Instruction 35 Alimony/Maintenance Payment [(Page 3, Schedule b) - See Instruction 17 (Please complete schedule B)] totAL deductions (Add Lines 19 to 21) chArgeABLe income (Line 15 minus Line 22) tAx on chArgeABLe income (25% oF Line 23) Total Tax Credits and Double Taxation Relief [(See Instructions 18 & 20) (Please complete schedule c)] totAL tAx credit Amount Limited to Line 24 income tax Liability (Line 24 minus Line 25) 20 21 22 23 24 25 26

to nearest dollar, omit cents/commas

PrePAYments 27 28 29 30 31 Tax Deducted Re: Cancellation of Approved Deferred Annuity/Pension Plan income tAx deducted (PAYe) Per td4 certiFicAte/s encLosed totAL PrePAYments (LINES 27 to 28) If Line 26 is greater than Line 29 - enter difference - Balance Payable If Line 26 is less than Line 29 - enter difference - refund 27 28 29 30 31

heALth surchArge comPutAtion

Rate per week (1) $ (a) Income more than $469.99 per month or $109.00 per week (b) Income equal to or less than $469.99 per month or $109.00 per week (c) Total Liability [Col. 3(a) + 3(c)] ... ... ... ... ... 8.25 $ 4.80 ... ...

No. of weeks (2) $

Liability (3)

$ ... ... ... ... ... ... $ $ $ $

(d) Health Surcharge Deducted per TD4 Certicate attached

(e) If Line (c) is greater than Line (d) - balance of Health Surcharge payable (f) If Line (c) is less than Line (d) - Overpayment ... ...

generAL decLArAtion it is An oFFence PunishABLe BY Fine or imPrisonment to mAke A FALse return PLeAse sign generAL decLArAtion
I, .................................................................................................. declare that in all statements contained herein and in any statement of accounts sent herewith I have to the best of my judgement and belief, given a full and true Return, and particulars of the whole of the Income from every source whatsoever required to be returned under the provisions of the Income Tax Act, Chap. 75:01 and the Finance Act, No. 14 of 1987. given under my hand this ...................... day of .........................................., 2013.
for official use only

..........................................................................
Signature of taxpayer, or authorized agent

Place Date Received Stamp Here

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2012
Form 440 emo
Bir no.

scheduLe A emPLoYers contriBution to APProVed Fund or contrAct [section 134(6) oF the income tAx Act] (See Instruction No. 16) comPutAtion to determine whether BeneFit is tAxABLe
to nearest dollar, omit cents/commas

1. 2. 3. 4.

Total Emolument Income at Page 1, Line 4 $............................ Plus Line 7 $............................ Employers Contributions to Approved Fund/Contract [TD4box 10, S. 134(6)] Total Income (Sum of Lines 1 to 2) ...

... ...

(a) Tertiary Education Expenses (Limited to $60,000 per household) (b) Employees Total Contributions to Approved Pension Plan /Scheme / Deferred Annuity Plan (c) National Insurance Payment [Total of (b) and (c) not to exceed $30,000] $ $

(d) First Time Acquisition of House (Limited to $18,000) (e) Covenanted Donation (See Page 1 Line 12)

...

totAL 5. 6. 7. 8. Subtotal - (Line 3 minus Line 4) Deduct Personal Allowance$60,000 Chargeable Income (Line 5 minus Line 6)

...

...

...

...
...

Compute 1 / 3 of Chargeable Income at Line 8 above, or 20% of Emolument Income at Page 1, Line 4 (whichever is greater) ... ... ... ... ... ... ... (a) Contributions by Employer to Approved Fund/Contract [TD4box 10] ...

...

...

...

...

9.

(b) Total Contributions by Employee to Approved Pension Plan/Scheme/Deferred Annuity Plan 10. Taxable benet. (Enter on Page 1, Line 8) (a) Where the total at Line 9 is greater than Line 8 the taxable benet is the total at Line 9 (a) (b) Where the total of Line 9 is less than the total of Line 8 the taxable benet is 0

scheduLe B ALimonY or mAintenAnce PAYments (Attach Copy of Court Order/Deed of Separation and Proof of Payment) (See Instruction No. 17)
name of spouse First Name deed of separation court order or decree Date (DDMMYYYY) Registered No. if spouse is a non-resident enter below withhoLding tAx inFormAtion Date Paid (DDMMYYYY)

Last Name

Country of Origin

Receipt No.

Tax Paid To Nearest Dollar, Omit Cents/Commas Address of spouse Street Birno. of spouse

mAintenAnce or ALimonY PAid City/Town Country Enter on Page 2, Line 21

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2012
Form 440 emo
Bir no.

scheduLe c tAx credits (See Instruction No. 18) (a) venture Capital Company in which Investment held (1) Amount of Investment (2) $ Venture cAPitAL tAx credit Highest Marginal Rate of Tax in year (3) % venture Capital Credit (2) x (3) (4) $ Credit brought Credit Claimed Credit to be Carried Forward Forward (4) + (5) (6) (5) (6) (7) $ $ $

enter total of column (6) in summary of tax credits, Line (a) cng kit And cYLinder tAx credit Motor vehicle Registration No. (1) Date of Purchase and Installation of CNg Kit and Cylinder (2) Total Cost of CNg Kit and Cylinder (3) $ Tax Credit - 25% of Total Cost Col. (3) x 25% (4) $ Tax Credit Claimed Limited up to Maximum of ($10,000) (5) $

(b)

enter total of column (5) in summary of tax credits, Line (b)

(c) Residential Address of Property (1)

soLAr wAter heAting eQuiPment tAx credit Date of Purchase of Solar Water Heating Equipment (2) Total Cost of Solar Water Heating Equipment (3) $ Tax Credit - 25% of Total Cost Col. (3) x (25%) (4) $ Tax Credit Claimed Limited to a Maximum of ($10,000) (5) $

enter total of column (5) in summary of tax credits, Line (c)

summArY oF tAx credits (a) (b) (c) venture Capital Tax Credit CNg Kit and Cylinder Tax Credit

to nearest dollar, omit cents/commas

Solar Water Heating Equipment Tax Credit

Total of Tax Credits, Lines (a) to (c), Enter Total on Page 2, Line 25

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