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LEMBAGA HASIL DALAM NEGERI MALAYSIA
INLAND REVENUE BOARD OF MALAYSIA
 Seksyen 109B Akta Cukai Pendapatan, 1967
 Section 109B Income Tax Act, 1967
AKAUN POTONGAN-POTONGAN DARIPADA PENDAPATAN KELAS KHAS DI BAWAH SEKSYEN 4A AKTA CUKA PENDAPATAN 1967
ACCOUNT OF DEDUCTION FROM SPECIAL CLASSES OF INCOME IN ACCORDANCE WITH SECTION 4A INCOME TAX ACT 1967

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Click explanatory notes before filling out this form
A.                                                                                     BUTIR-BUTIR PEMBAYAR
                                                                                                                           PARTICULARS OF PAYER



 
No. Cukai Pendapatan *(sila lengkapkan)
Income Tax No.*(please complete)
Nama Pembayar
Name of Payer
Alamat Pos
Postal Address
Poskod
Postcode
Bandar Town
Negeri
State
B.           BUTIR-BUTIR MENGENAI ORANG YANG TELAH DIBAYAR / DIKREDITKAN PENDAPATAN KELAS KHAS
                                                  PARTICULARS OF PERSON TO WHOM THE SPECIAL CLASSES OF INCOME  HAD BEEN PAID / CREDITED



 
No. Cukai Pendapatan Malaysia (jika ada)
Malaysian Income Tax No.(if any)
Nama Penuh Penerima
Name of Payee
Alamat
Address
Poskod
Postcode
Bandar Town
Negeri
State
Negara Asing
Foreign Country
C.                                                            BUTIR-BUTIR MENGENAI POTONGAN-POTONGAN
                                                                                                                PARTICULARS OF DEDUCTIONS
Kategori Bayaran
Category of Payments
Tempoh dimana bayaran dibayar/dikredit
Period for which the said payment was paid/credited
(hhbbtttt)
Tarikh bayaran  telah dibayar/dikreditkan.
Date the payment was
paid/credited.
(hhbbtttt)
Amaun bayaran kasar
(sertakan salinan invois)
Amount of gross payment
(attach copy of invoice)
Amaun potongan di bawah Seksyen 109B (kadar 10%)
Amount of deduction under Section 109B(rate 10%)
Amaun bersih
dibayar/dikreditkan
(sertakan salinan dokumen).
Net Amount paid/credited(attach copy of document)


RM RM RM
Saya, bagi pihak saya sendiri / bagi pihak Pembayar di atas telah membuat potongan daripada amaun bayaran golongan pendapatan kelas khas yang disebutkan di atas ini dan mengemukakan akaun ini menurut peruntukan Seksyen 109B(1) bersama dengan bukti dokumen tarikh pembayaran yang telah dibuat/dikreditkan.
I,  on my own behalf/on behalf of the above mentioned payer have made deductions from the above-mentioned amount of special classes of income and render this account in accordance with the provisions of Section 109B(1) together with documentary evidence of the date payment was paid/credited
Saya sertakan bersama ini wang tunai/cek No:
I enclose herewith cash/cheque No:
Amaun
Amount
RM
Nama
Name
Jawatan
Designation
No. Telefon
Telephone No.
Tarikh:
Date:
27/06/2022
                                                                      

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