This document contains sections for an individual annual income tax return form, including parts for assets and liabilities at year-end, a list of family dependents, and sections to provide details of assets, liabilities, and dependents such as names, relationships, dates of birth, addresses of lenders, years of acquisition and lending, and amounts. The document instructs the taxpayer to print clearly, mark appropriate boxes, and add additional pages if needed to complete the form.

1. • to
 DEEMED ACCOUNTING
ATTENTION
• FOLLOW INSTRUCTION IN THE MANUAL
• PRINT OR TYPE WITH CAPITAL LETTER OR BLACK INK
• MARK " X " IN THE
T I N :
TAXPAYER'S NAME :
PART A :
PART B : LIABILITIES/PAYABLES AT YEAR-END
PART C : LIST OF FAMILY DEPENDENT
from pages of Attachment-IV
INDIVIDUAL ANNUAL INCOME TAX RETURN
5.
6.
7.
8.
NAME OF LENDER
NAME OCCUPATION
(2) (3) (4) (5)
RELATIONSHIP IN FAMILYDATE OF BIRTH
5.
etc
1.
9.
10.
etc
2.
3.
4.
TOTAL PART B
(1)
TPB
NO.
(3)
TPATOTAL PART A
ADDRESS OF LENDER
(5)
TOTAL
(IDR)
(4)
(1)
(2)
YEAR OF LENDING
4.
1.
NO.
3.
(1)
8.
6.
10.
etc
1.
2.
•
2.
7.
9.
5.
ASSETS AT YEAR - END
TAXABLEYEAR
MM
1770 - IV
MM YY
DIRECTORATE GENERAL OF TAXES
MINISTRY OF FINANCE
3
4.
(4)
COST OF ACQUISITION
(IDR)
TYPE OF ASSETS
02
APPROPRIATE BOX
ASSETS AT YEAR-END
ATTACHMENT - IV
YEAR OF ACQUISITIONNO.
FORM
(5)
YY
LIABILITIES AT YEAR- END
PageIF NEEDED, ADDITIONAL PAGES MAY BE ADDED
DESCRIPTION
(3)(2)
LIST OF FAMILY DEPENDENT