Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697797026411.pdf (Dominica)
Form I.T.
4(B) Commonwealth of Dominica Inland Revenue Division Individual Return of Income for the Year ended December 31st _____ Last Name First Name Middle Name(s) Tax Account Number Home Address Mailing Address (if different from home address) Name & Address of Employer Sex M F Date of Birth Social Security Number Nationality Marital Status Name of Spouse Telephone Number (Home) Telephone Number (Work) Telephone Number (Mobile) Occupation Email Address COMPUTATION OF NET INCOME 1000 Wages and salary from Employment 1001 Less: Allowable Employment Deductions (complete Schedule A-page 3) 1002 Less: Exempt Income (Sickness/Maternity Benefit refunded to your employer – attach statement) 1003 Net Employment Income (subtract line 1001 & 1002 from line 1000) 1000 1001 1002 1003 1200 Alimony or Maintenance receipts 1201 Gross Taxable Dividends (complete Schedule B – page 3) 1202 Annuities 1203 Net Taxable Income From Operation (complete Schedule G & G2) (Example: Business Income.
Professional Income.
Rental Income, etc...) 1204 Share of Income/Loss from Partnership 1205 Share of Income/Loss from Estate or Trust 1206 Income earned overseas (give details on a separate sheet) 1207 Total Income (add lines 1003 to 1206) 1208 Less: Prior Year(s) Loss (from bona fide businesses only – complete Schedule D – page 3) 1209 Net Taxable Income (subtract line 1208 from line 1207) COMPUTATION OF ALLOWANCE & DEDUCTIONS 2000 Allowance for Resident Individuals ($25,000.00) 2001 Mortgage Interest (maximum allowable $25,000.00 - attach statement) 2002 Approved Donations (attach receipts) 2003 Student Loan Interest (maximum per student $5,000.00; attach statement) 2004 Total Allowances and Deductions (add lines 2000 to 2003) 2000 2001 2002 2003 2004 1200 1201 1202 1203 1204 1205 1206 1207 1208 1209 2005 Chargeable Income (subtract line 2004 from line 1209 and carry forward to page two) 2005 INDIVIDUAL RETURN OF INCOME – PAGE TWO Form I.T.
4(B) 2005 Chargeable Income (brought forward from page one) 2005 COMPUTATION OF TAX ON CHARGEABLE INCOME SELECT ONE (1) OF THE FOLLOWING THREE (3) CONDITIONS AND ENTER THE RESULT IN THE ‘TAX PAYABLE’ COLUMN Condition 1: use if Chargeable Income is between $0 and $20,000 Chargeable Income Tax Payable Enter Chargeable Income from line 2005 Enter total tax payable on line B and carry to line 3000 A x 15% B Condition 2: use if Chargeable Income is between $20,001 and $50,000 Chargeable Income Tax Payable $20,000 00 $3,000 00 x 25% D Chargeable Income Tax Payable $50,000 00 $10,500 00 Enter Chargeable Income from line 2005 Tax on the first $20,000 Difference (minus line B from line A) Enter total tax payable on line D (line B plus line C) and carry to line 3000 Condition 3: use if Chargeable Income is greater than $50,000 Enter Chargeable Income from line 2005 Tax on the first $50,000 Difference (minus line B from line A) Enter total tax payable on line D (line B plus line C) and carry to line 3000 A B C A B C 3000 Total tax payable on Chargeable Income (base on conditions 1, 2 or 3) LESS: CREDITS AND PAYMENTS 3001 Dividend Tax Credit (From schedule B) 3002 Double Tax Credit (From schedule C) 3003 New Employment Rebate (Maximum $600 per position or $6000 per Tax Period) 3004 Total Credits & Rebate (add lines 3001 to 3003 – Should not exceed line 3000) 3005 Net Tax Payable after Credits & Rebate (line 3000 less line 3004) 3006 PAYE deductions (employees only) 3007 Installment Payments 3008 Payments on account 3009
 Total Payments (add lines 3006 to 3008) 3010 Difference (subtract line 3009 from line 3005) 3011 Add: Late-filing Penalty (multiply line 3000 by 5%) 3012 Total amount Payable/Refundable (add line 3010 to line 3011) 3013 Amount paid on filing 3001 3002 3003 3006 3007 3008 3009 x 35% D 3000 3004 3005 3010 3011 3012 3013 I hereby certify that the information given in this return is TRUE, CORRECT and COMPLETE in every respect and FULLY DISCLOSES my TAXABLE INCOME from ALL SOURCES CERTIFICATE OF DISCLOSURE Name Date Day Month Year Signature 1.
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Make cheque or money order payable to the COMPTROLLER OF INLAND REVENUE.

DO NOT MAIL CASH Return MUST be filed ON OR BEFORE MARCH 31st Any balance due MUST be paid ON OR BEFORE MARCH 31st A 10% PENALTY AND INTEREST AT 1% PER MONTH OR PART THEREOF will be charged on payments made after MARCH 31st If you require assistance in completing this form, contact the Inland Revenue Tel no: 266-3600 or Email: irddom@cwdom.dm INDIVIDUAL RETURN OF INCOME – PAGE THREE Form I.T.
4(B) Schedule A Claims for deductions against Employment Income (Expenses must be wholly, exclusively and necessarily incurred in the production of your Assessable Income) (Do not include Mortgage Interest, Resident Allowance, Social Security contributions or PAYE deductions) Schedule B Part I – Dividends received during the year from Resident Companies Payer’s Name Address Type of Distribution Amount / fair market value 1.

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4.
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Total value of Dividends and Distribution (add lines 1 to 4) Less: Distribution of Exempt Income Gross taxable Dividends and Distribution (enter on line 1201) Part II – Tax Credit for Dividends paid by Resident Companies What is the rate at which the inclusion of Gross Taxable Dividends (above) causes an increase in computing the tax on Chargeable Income?
% (A) If the rate is 30% or less, enter the amount of the additional tax payable here (carry this amount in line 3001) (B) If the rate is increased by more than 30%, then a Tax Credit equal to 35% of the Dividend here (carry this amount in line 3001) (A) (B) Schedule C Double Taxation Credit Name of Payer Company (group according to Country) Type of Income % share of Ownership in Paying Company Gross Foreign Income Declared Rate of Foreign Tax Double Tax Credit Claimed 1.

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Total Double Tax Credit Claimed (add lines 1 to 5 and enter amount on line 3002) Total Gross Foreign Income (add lines 1 through 5) Schedule D Loss from Prior Years(s) Year of Loss Assessment Number Amount of Loss Prior Set-off’s Amount Year of Income Balance of Loss Allowable For set-off Amount set-off This Income Year $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ INDIVIDUAL RETURN OF INCOME – PAGE FOUR Form I.T.
4(B) SCHEDULE G PROFIT & LOSS STATEMENT 1100 Gross Sale of Goods/Services (including goods used by proprietor & family) 1100 Less: Cost of Sales/production 1101 Opening Inventory/Stock 1102 Purchases 1103 Closing Inventory/Stock 1104 Cost of Sales/Cost of Production (line 1101 plus line 1102 less line 1303) 1105 Gross Profit (line 1100 less line 1004) 1106 Royalty Income 1107 1108 1109 Commission, Discounts, Fees, License Charges, and Premium Income Insurance Receipts on Claims Gains/losses on asset disposal 1110 Other Income (attached breakdown) 1111 Total Income (add lines 1105 to 1110) 1101 1102 1103 1104 1106 1107 1108 1109 1110 Less: Operating Expenses 1112 Salaries & Wages/Allowances, including Social Security paid by Employer 1112 1113 Less: Proprietor’s Salary 1114 Salaries/Wages of Employees (subtract line 1113 from line 1112) 1115 Advertising & promotion 1116 Amortization(depreciation) of Intangible & Tangible Assets 1117 Bad Debt Expense 1118 Bank Charges (including interest on business loans/overdraft) 1119 Business taxes, licenses & rates 1120 Utilities and Telephone 1121 Rental/Lease (on business property) 1122 Repairs & Maintenance 1123 Insurance Premiums 1124 Sub-Contracts 1125 Motor Vehicle Operating Expenses 1126 Travelling Expenses (not included in line 1125) 1127 Stationery and Postage 1128 Other operating expenses (attach breakdown) 1129 Total Operating Expenses (add lines 1114 to 1128) 1130 Net Profit/(Loss) (line 1111 less line 1129) 1113 1114 1115 1116 1117 1118 1119 1120 1121 1122 1123
 1124 1125 1126 1127 1128 1105 1111 1129 1130 INDIVIDUAL RETURN OF INCOME – PAGE FIVE Form I.T.
4(B) Schedule G2 Reconciliation of Chargeable Income with Profit/(Loss) 1.

2.

Net Profit/(Loss) (From Schedule G - line 1130) Add/Deduct: Expenses not Allowable a. b. c. d. e. f. Total Sub Total 3.

Deduct/Add: Expenses not charged and Exempt Income included in Accounts a. b. c. d. e. f. Total 4.

Adjusted Net Profit/(Loss) (enter this amount on line 1203 of Page One) This reconciliation is required under section 73(1) of the Income Tax Act Did you pay to have your return completed?
If yes, please complete the section below: Name of of Individual/Company Address Amount Paid