1. Data on state body

_______________________________________________

(name and location of tax authority)

  "____" _____________  _____ of year                         _______________________________ 

     (acceptance date of the declaration)                            (signature of the head of tax authorities)

2. Information about the customs applicant

1. Surname, name and middle name of the customs applicant

2. Post and place of employment

3. Identification taxpayer number

4. Residence, phone number, e-mail address

5. Accounting period (from January 1 to December 31 20 ___)

3. Data on the income

№

List of the income, including abroad

Income amount

(in somoni)

Paid amount of tax (in somoni)

1

The income on principle place of employment

2

The income on nonbasic place of employment (in case of work in two or more places with indication of the nonbasic place (nonbasic places) of work)

____________________________________________

3

The income from scientific, creative and pedagogical activities (with indication of types of activity and place of employment)

____________________________________________

4

The income from the property leased

5

Income from the homestead parcel of land

6

The income from the earth received (rented)

7

Income from bank deposits

8

The income about shares in the authorized capital of the commercial organizations (including, dividends from shares) and other securities

9

Other income (with indication of income type)

____________________________________________

Total on Items 1 - 9

Note: If for placement of the name of the income in the corresponding Items of Chapter 3 there are not enough lines, then the customs applicant shall open new lines and enter data.