PART A: PERSONAL PARTICULARS

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If Married, State Spouse's Information

PART B: SOURCE OF INCOME

PART C: INCOME AND TAX FOR THE CURRENT AND PREVIOUS YEARS

PENALTY FOR DEFAULT

Please note that in accordance with the relevant law, making false statement and returns or unlawful to pay tax will attract up to five (5) years imprisonment

DECLARATION

I Hereby declare that information supplied in this form contain a true and correct statement of the amount of my income from all sources.