REQUEST FOR BOARD OF INLAND REVENUE APPROVAL

GOVERNMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO
REQUEST FOR BOARD OF INLAND REVENUE APPROVAL
Complete in Duplicate
DETAILS OF CONTRIBUTIONS TO FUND OR CONTRACT IN ACCORDANCE
WITH SECTION 134(6A) AND (6B) OF THE INCOME TAX ACT CHAPTER 75:01
NOTE:
(i) The Board of Inland Revenue hereby requires you to give the following information pursuant to Section 117
of the Income Tax Act, Chapter 75:01.
(ii) Section 119 of the Income Tax Act, Chapter 75:01 provides that any person who makes a false declaration is liable on
summary conviction to a fine of Eight Thousand Dollars ($8,000.00) or imprisonment of three (3) years, or to both such
fine and imprisonment.
(iii) If there are changes in Income or Contribution, the Board of Inland Revenue must be informed immediately.
(iv) Original or certified pay slip / Copy of TD1 approved by the Board must be submitted with request.
INCOME YEAR 20___
1. NAME OF EMPLOYER---------------------------------------------------------------------------------------
2. ADDRESS OF EMPLOYER ---------------------------------------------------------------------------------
3. EMPLOYER’S B.I.R.FILE NO. -----------------------------------------------------------------------------
4. NAME OF EMPLOYEE --------------------------------------------------------------------------------------
5. ADDRESS OF EMPLOYEE----------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
6. Annual Contributions to be made in respect of employee to;
Company (a) …………………………… $...........................
(b) ………………………… $ ……………….. $ ------------------------------
7. Annual Contributions made by employee to Approved Plan(s) $ ------------------------------
(Total of Lines 6 (a) (i) to (iii) and 6 (b) overleaf)
8. Total Contributions - Lines (6) and (7) $ ------------------------------
9. One third (1/3) Chargeable Income) as per overleaf (Line 9) $ ------------------------------
10. Do the Total Contributions (Line 8) exceed
one third (1/3) Chargeable Income) ( )Yes ( ) No
11. 20 per cent of Emolument Income - as per overleaf (Line 10) $ -------------------------------
12. Do the Total Contribution at (Line 8) exceed the
20 % of Emolument Income- Line 11. ( ) Yes ( ) No
N.B. Maximum Contributions to be made are the greater of Line 9 OR Line 11.
__________________________________
Signature of Employer & Company’s Stamp
1

EMOLUMENT INCOME COMPUTATION
Round figures to the nearest dollar, omit cents
1. Emolument Income
(Inclusive of contributions to S.134 (6) plans)
(a) $ ----------------------
(b) $ ---------------------
TOTAL EMOLUMENT INCOME $ ------------------------
2. Add: Other Income (Net) $ ------------------------
3. TOTAL NET INCOME $-------------------------
4. Deduct: (1) Personal Allowance (Residents only - $60,000.) $---------------------
(2) Tertiary Education Expenses (Limited to $60,000) $--------------------
(3) First Time Home Owner $--------------------
(Limited to $10,000; up to Income Year 2009)
5. Assessable Income $ ------------------------
6. Deduct:
(a) Contributions/Premiums Paid
(i) Government Widows and Orphans Fund $ ---------------------
(ii) Approved Pension Fund Plan $ ---------------------
(iii) Approved Deferred Annuity Plan $ ---------------------
(b) N.I.S. (70%) $ ---------------------
7. Total Lines 6(a) (i) to (iii) and (b) limited to $30,000 $ ---------------------------
8. Chargeable Income (Line 5 minus Line 7) $ ---------------------------
9. One third (1/3) Chargeable Income $ ---------------------------
10. Twenty (20) % of Line (1) Total Emolument Income $....................................
_________________________________
Employee’s Signature/Date
_________________________________
Employee’s B.I.R. File No.
2

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