Income Tax Return for Individuals Taxpayer Ref Year of Assessment ITR12

(Income Tax Act, No. 58 of 1962, as amended) No.

0 2 2 2 2 0 5 1 7 1 2 0 1 8
Taxpayer Information
Personal Details

Surname T H E K I S O
First Name T H O M A S S A M O R A
Other Name

Initials Date of Birth ID No.

T S (CCYYMMDD) 1 9 8 3 1 2 0 8 8 3 1 2 0 8 5 6 3 8 0 8 9
Passport Passport Country (e.g. South Africa = ZAF)
No. Passport Issue Date (CCYYMMDD)

Marital Not Married (Single, Divorced, Widow / Widower) Married in Community of Property Married out of Community of Property
Status

Spouse Details

Initials ID No.

Passport Passport Country (e.g. South Africa = ZAF) Z A F

No.

Contact Details

Email t . t h e k i s o 1 9 8 3 @ g m a i l . c o m
Mark here with an "X" if you declare that you do not have an email address IMPORTANT: The security details that SARS has on record for you are used for One-Time PIN's (OTP) and authentication purposes. eFilers will
only be able to update security contact details via the SARS Registered Details menu on eFiling, the SARS eFiling App or at a SARS branch.
Cell No. 0 8 3 6 9 3 1 2 6 6
Declaration
Mark here with an "X" if you declare that you do not have a cell phone number

Home I declare that:

Tel No. • The information furnished in this return is true and correct in every respect; and
• I have disclosed in full the gross amounts of all income accrued to or received by me during the period covered by this xxxxxxxxxxxxxxxxxxxxxxxxx
return; and xxxxxxxxxxxxxxxxxxxxxxxxx
Bus Tel No. • I have the necessary receipts and records to support all my declarations on this form which I will retain for inspection
purposes.

Fax No. Please ensure you sign over

the 2 lines of “X”s above
Date For enquiries go to www.sars.gov.za or
Do you confirm that the email and telephoine numbers(s) (CCYYMMDD) call 0800 00 SARS (7277)
Y N
supplied are correct?

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 Physical Address Details

Complex
Unit No. (if applicable)
Street No. Street / Farm
2 5 Name B U T I S T R E E T
Suburb /
District K W A - T H E M A
City / Town S P R I N G S Country Code Z A
Postal Code 1 5 7 5

Postal Address Details

Mark here with an "X" if same as above or complete your Postal Address. Is your Postal Address a Street Address? Y N

Postal Agency or Other Sub-unit (if applicable) (e.g. Postnet Suite ID)

PO Box Private Bag Other PO Special

Service (specify) Number

Post Office Country Code

Postal Code

Complex
Unit No. (if applicable)
Street No. Street / Farm
2 5 Name B U T I S T R E E T
Suburb /
District K W A - T H E M A
City / Town S P R I N G S Country Code Z A
Postal Code 1 5 7 5

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 Bank Account Holder Declaration
I use South African I use a South African Bank I declare that I have no
bank accounts Account of a 3rd party South African bank account
Reason for No Local / 3rd Party Bank Account

Non-residents without a Deceased Estate Shared Account Income below tax Statutory restrictions
Insolvency / Curatorship threshold / Impractical Minor child
local bank account

Bank Account Details

Bank Account
Status Account No. X X X X X X X 1 3 0 1 All changes will be verified before updating your banking profile. SARS will let you know if you need to
come in to a SARS branch with supporting documents. Bank details are required for refunds.
Branch No. 4 6 2 0 0 5 Account Type: Cheque Savings Transmission

Bank Name B I D V E S T B A N K
Branch Name B I D V E S T B A N K
Account Holder
Name (Account T H E K I S O T S
name as registered
at bank)
Agreement Statement

Mark here with an ‘X’ if you do declare that this information is true and correct in every respect.

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 Employee Tax Certificate Information [IRP5 / IT3(a)]

Employer Name A L E X A N D E R F O R B E S F I N A N C I A L S E R V I C E S
Year of Assessment PAYE
Certificate No. 7 9 5 0 7 1 7 6 4 7 2 0 1 8 0 2 0 0 0 0 0 0 1 3 2 3 0 6 7 8 (CCYY) 2 0 1 8 Ref No. 7 9 5 0 7 1 7 6 4 7
Income Received Income Received continued... Tax Credits and / or Employer / Employee Contribution

Amount Source Code Amount Source Code PAYE R , 4102

R Non-Taxable Income
6 7 5 9 3 3 9 2 0 PAYE on Lump Sum Benefit
R 3 6 9 6 R 7 0 9 9 ., 7 6 4115
R
Gross Employment Income (Taxable) Employee and Employer UIF Contribution
R
R 6 7 5 9 3 3 6 9 9 R 0 ., 0 0 4141
R
Employer SDL Contribution
R R 0 ., 0 0 4142

R Total Tax, SDL and UIF

Deductions / Contributions / Information
R R 7 0 9 9 ., 7 6 4149
R
Medical Scheme Fees Tax Credit
R
R R 4116
0 ., 0 0
R
R Additional Medical Scheme Fees Tax Credit
R R 4120
R ,
R 4150
R Reason for Non-Deduction of Employees' Tax

R
R Pay Periods

R Periods in Year of Assessment 1 ., 0 0 0 0

R
R R No. of Periods Worked 1 ., 0 0 0 0
R R Period Employed From (CCYYMMDD) 2 0 1 7 0 5 0 9
R R Period Employed To (CCYYMMDD) 2 0 1 7 0 5 0 9
R R Directive Numbers

R R Directive No. 0 0 0 0 0 0 0 2 1 7 6 2 9 6 3
R Total Deductions / Contributions
Directive No.
R 4 4 9 7
R
Directive No.

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 Employee Tax Certificate Information [IRP5 / IT3(a)]

Employer Name R O A D S P A N S U R F A C E S ( P T Y ) L T D
Year of Assessment PAYE
Certificate No. 7 1 2 0 7 6 8 4 3 9 2 0 1 8 0 2 S 7 0 6 0 0 5 0 1 4 8 0 0 0 (CCYY) 2 0 1 8 Ref No. 7 1 2 0 7 6 8 4 3 9
Income Received Income Received continued... Tax Credits and / or Employer / Employee Contribution

Amount Source Code Amount Source Code PAYE R 2 2 7 6 7 ., 8 5 4102

R Non-Taxable Income
6 5 7 9 9 3 6 0 1 PAYE on Lump Sum Benefit
R 3 6 9 6 R , 4115
R 6 6 1 4 3 6 0 5
Gross Employment Income (Taxable) Employee and Employer UIF Contribution
R 5 3 2 0 3 7 0 1 R 8 1 1 4 4 3 6 9 9 R 2 9 7 ., 4 4 4141
R 2 1 4 3 8 0 1 Employer SDL Contribution
R 1 0 4 9 3 8 1 0 R 7 5 5 ., 8 1 4142

R 2 1 4 6 3 8 2 5 Total Tax, SDL and UIF

Deductions / Contributions / Information
R R 2 3 8 2 1 ., 1 0 4149
R 4 4 9 8 4 0 0 3
Medical Scheme Fees Tax Credit
R
R 2 0 4 7 4 0 0 5 R 4116
3 0 3 ., 0 0
R
R 1 0 4 9 4 4 7 4 Additional Medical Scheme Fees Tax Credit
R R 4120
R 4 2 5 6 4 5 8 2 ,
R 4150
R Reason for Non-Deduction of Employees' Tax

R
R Pay Periods

R Periods in Year of Assessment 1 2 ., 0 0 0 0

R
R R No. of Periods Worked 1 ., 0 0 0 0
R R Period Employed From (CCYYMMDD) 2 0 1 7 0 3 0 1
R R Period Employed To (CCYYMMDD) 2 0 1 7 0 3 3 1
R R Directive Numbers

R R Directive No.

R Total Deductions / Contributions

Directive No.
R 1 1 8 5 0 4 4 9 7
R
Directive No.

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 Taxpayer Information - Deductions Qualifying Criteria for the Deduction of Foreign Taxes Paid or
Physical Impairment
Proved to be Payable to a Foreign Government of any Country on
Medical Deductions - Rands only, no cents State any qualifying physical impairment expenses paid by you and not recovered any SA Sourced Trading Income (including salary income) -
from any medical scheme(s) and not included above. Rands only, no cents
Medical expenditure (including medical scheme
contributions made by you or your employer towards a R 4022 Did you have a right of recovery other than a right of recovery i. Y N
medical scheme where you are the principal / main t.o. a mutual agreement procedure, or any entitlement to carry
member) Disability back losses arising during any previous year of assessment?
Was this foreign tax amount refunded to you during this year of Y N
Were you the principal /main member of a medical scheme Y N Are you, your spouse or any of your qualifying children a assessment?
to which you and / or your employer made contributions? Y N
person with a disability?
In how many medical scheme(s) were you a the principal / main Taxable income from SA sourced trade income (including salary income) taxed outside
member during this year of assessment?
1 If ‘Yes’, has this the disability been confirmed by a duly
registered medical practitioner as prescribed? Y N SA (before taking into account any allowable deductions i.t.o. s11F, s18A and
Details of Medical Scheme s6quat(1C), as these deductions will be calculated by SARS)
Indicate the number of qualifying person(s) with a disability:
Medical Scheme Name: Note: This income must have been declared elsewhere in this return.
Qualifying criteria for s10(1)(o)(ii) exemption ( excluding s8A/8C
Discovery Health Medical Scheme gains and dividends) R

Are you a SA resident as defined in the Income Tax Act? Y N

Medical Scheme Membership Number
Were you employed to render services outside SA? Y N
1.4899009.1122233925.MED.2017.3 If yes, please state the number of days you were outside
SA during any 12 month qualifying period:
Start date of the 12 month qualifying
State the total number of dependants (including yourself) per month:
period (CCYYMMDD)
Mar Apr May Jun Jul Aug End date of the 12 month qualifying
period (CCYYMMDD)
1 0 0 0 0 0 Total number of full days outside SA during the 12 month
Oct Jan Feb qualifying period
Sep Nov Dec
Did you within the period indicated above spend a
Y N
0 0 0 0 0 0 continuous period exceeding 60 full days outside SA?
Total number of work days during the above qualifying period relating to
State the total medical contributions made by yourself and / or your employer to this this year of assessment
scheme (incl. subsidies from former employer) Total number of work days outside South Africa during the above qualifying
R 2 0 4 7 4005 period relating to this year of assessment.
Total remuneration received / accrued in this year of assessment in respect of foreign
State any medical expenses paid by you that was claimed from your medical scheme services rendered
and reflected on the medical certificate. (other than physical impairment or disability
expenses) R
R 6 4 7 4 4020 Remuneration exempt

R
Expenses not reflected on any medical certificate
Qualifying criteria for s10(1)(o)(ii) exemption relating to s8A/8C
State any qualifying medical expenses paid by you that was not claimed from any gains (excluding dividends)
medical scheme and not reflected on any medical scheme certificate (other than
physical impairment or disability expenses) Are you a SA resident as defined in the Income Tax Act? Y N
R 4034
In respect of the s10(1)(o)(ii) exemption claimed, how many
s8A/8C gains are applicable during this year of assessment?

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