Taxation :: Self Assessment LIRS

PART A: Applicable during the YEAR ENDED 31ST DECEMBER, 20:

Full Name:

In this order Surname; First name; Middle Name

Title (Mr./Mrs./Ms./Others):

Marital Status (Married / Single/ Others):

Date of Birth:

Current Residential Address:

House No, Street, Town/Area, LG/LCDA, State

Nationality:

Occupation:

LASRRA No:

Fill in the number E.G LA 12345

Contact Tel. No(s):

Email:

Name and Address of Employer/Business:

Give particulars and dates:

If any change in the above circumstances had occurred during or since the year ended 31st December, 20__

Date of Arrival in Nigeria:

DD/MM/YYYY

Date of Departure from Nigeria:

DD/MM/YYYY

Residence (Full Address) :

At 1st January 20__

If Married, Spouse's Full Name:

Spouse's Date of Birth:

DD/MM/YYYY

Spouse's Employer/Business:

Spouse's Occupation:

Children's Information :

Full Name, Date of Birth, Name and Address of educational establishment, Child’s income in his or her own right (N)

Trade, Business, Profession, Vocation etc.:

Annex copies of Accounts for the Year Ended 31st December 20……….

Employment: Salary:

Employment: Commissions, Bonuses, etc.:

Employment: Allowances :

Pension From:

Annuities From:

Gratuities :

Income received in or brought into Nigeria from all sources outs:

Aggregate earned income from all sources:

Dividends from Nigerian Companies Other Dividends:

Enter the gross Amount before deduction of tax

Interest :

Rents :

Income arising from sources not included above :

PART C: Benefits-in-kind: A. Residential Address:

a(i). As at January 20.... :

a2. Changes during the year:

A3. Length of Stay:

B:

Lanlord
Tenant
Other

C. Rent Paid:

D. Name and Address of Owner of Premises:

E. Accommodation type:

F. Rental Period:

G. Rent Paid by Employer:

G(i). Location of Accommodation:

H. Rent Paid or Reimbursed by you:

I. Names of Domestic Servants :

List the name, Address and amount paid for each. Asterisks those aid by your employers

J. Vehicle(s) :

Note: Please asterisk those paid for by your employer or a separate entity apart from self, and annex the details.

PART D: Other mandatory disclosures. A. Do you have share a shar:

Yes
No

B. Do you make voluntary contributions to a Retirement Savings A:

Yes
No

B(i) Did you make any withdrawals from the RSA in the year?:

Yes
No

PART E: Assets as at 31st December, 20………. :

1. Tangible Immoveable Properties :

PART F: Claim for Capital Allowance 1. Annex File :

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2. Claim for relief on interest on loan for mortgage. Annex File :

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PART G: Allowances for Life Assurance, Gratuities, NHIS, Pension :

Name of Company, Whether on Life of Self or Spouse Capital sum paid on death, Premiums PAID during the year ended 31st December, 20.... (To the nearest N);

Self Assessment LIRS

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