Department of Inland Revenue

Declaration in terms of Section 133 of the Inland Revenue Act.

YEAR OF ASSESSMENT : ..
To

Manager - Sampath Bank PLC

........................................Branch

Account No./s:

(1) .
(2) .
(3) .

(4)..
(5)..
(6)..

DECLARATION (Individuals)
I (Full Name) of

.(Address) hereby declare that:

The Assessable Income (Total Income excluding exempt income) for the above year
of assessment is less than Rs.500,000/-* (No Tax)
The Assessable Income (Total income excluding exempt income) for the above year
of assessment is more than Rs.500,000/- but less than Rs.1,500,000/- * (2.5% Tax)
The Assessable Income (Total income excluding exempt income) for the above year
of assessment is more than Rs.1,500,000/- * (8% Tax)
* Please Tick (
) the relevant statement.
Tax File No: (If any) .................
National Identity Card No: ...................................
I certify that the above declaration made by me is true and correct.

-------------------Date

-----------------------------------Signature of the Declarant

We acknowledge the receipt of the Declaration for the Year.

Name

Account No

Date

Authorized Signatory

foaYSh wdh fomdrA;fka;=j

cs;ehl;L ,iwtupj; jpizf;fsk;
foaYSh wdh mkf;a 133 j.ka;sh m%ldrj m%ldYh
cs;ehl;L ,iwtupr; rl;lk; gpupT 133
133 ,d; fPo; Nkw;nfhs;Sk;; gpufldk;
;lafiare jrAIh
(
kjpg;gl
P L
; tUlk;
:
:
l<uKdlre
- ism;a nexl=j mSt,aiS fj;
Kfhikahsu;- rk;gj; tq;fp gp vy; rp
YdLdj fpis
.sKq wxl/h - wxl 1
fzf;F ,yf;f/q;fs; 2
3

4
5
6

m%ldYh ^mqoa.,hska& gpufldk;

gpufldk (jdp egu;fs;)
^ismr
Q AK ku& jk vDk;
(KOg;ngau;); cila

^,smskh&ys mosxps ud
Nkw;Fwpg;gpl;l tpyhrj;jpy; trpf;Fk; ehd;
by; ;lafiare jrAIh i|yd udf.a ;lafiare l<yels wdhu^ksoyia wdhu yer uq wdhu&
re500000$-g wvq nj;a * ^n ke;&
Nkw;Fwpg;gpl;l kjpg;gl
P L
; tUlj;Jf;Fupa tuptpjpg;Gf;Fupa tUkhdk; (tpyf;F mspf;fg;gl;l tUkhdk;
jtpu;ej
; KO tUkhdk;) & 500>000/-f;F FiwT *(tup
(tup ,y;iy)
by; ;lafiare jrAIh i|yd udf.a ;lafiare l<yels wdhu ^ksoyia wdhu yer uq wdhu &
re500000$-g jevs kuq;a /1500000$- wvq nj;a * ^noao 25])
25]
Nkw;Fwpg;gpl;l kjpg;gl
P L
; tUlj;Jf;Fupa tuptpjpg;Gf;Fupa tUkhdk; (tpyf;F mspf;fg;gl;l tUkhdk;
jtpu;ej
; KO tUkhdk;) & 500>000/-f;F mjpfkhfTk; Mdhy; &1,500>000/- I tpl FiwT *(2.5
(2.5%
(2.5
tup )
by; ;lafiare jrAIh i|yd udf.a ;lafiare l<yels wdhu ^ksoyia wdhu yer uq
wdhu&
re1500000$-g jevs nj;a * ^noao 8]&
Nkw;Fwpg;gpl;l kjpg;gl
P L
; tUlj;Jf;Fupa tuptpjpg;Gf;Fupa tUkhdk; (tpyf;F mspf;fg;gl;l tUkhdk;
jtpu;ej
; KO tUkhdk;) & 1,500>000/- I tpl mjpfk; *(8
(8%
tup )
(8
fuhska m%ldY lrus

,t;thW gpulfdg;gLj;Jfpd;Nwd;.

* w, m%ldYh (
) fhdod i,l=Kq lrkak * jaT nra;J nghUj;jkhd mwpf;ifapid (
() Fwpg;gplTk;.

n ,smsf.dkq wxlh ^we;akus& /tupf; Nfhg;G ,y:(,Ue;jhy;) :

cd;sl yekqusm;a wxlh /Njrpa milahs ml;il ,yf;fk; :

ud jsiska lrk ,o m%ldYh i;H yd ksjeros nj fuhska ;jrg;a m%ldY lrus vd;dhy; NkNy
Fwpg;gplg;gl;l gpufldk; cz;ikahdJk; rupahdJk; vd cWjpg; gLj;Jfpd;Nwd;.

oskh jpfjp

m%ldYlhdf.a w;aik gpufldg;gLj;Jgtupd; ifnahg;gk;

uQ,H jrAIh i|yd imhk ,o m%ldYh ,enqKq njg iy;sl lruq

ehq;fs; tUlj;Jf;fhd gpufldj;jpid ngw;Wf; nfhz;ljhf cWjpg;gLj;Jfpd;Nwhk;.
ku ngau;

.sKqus wxl/h fzf;F ,yf;f/q;fs;

oskh

jpfjp

n,h,;a ks,Odrs mjpfhukspf;fg;gl;l ifnahg;gjhup