DLN:
Certificate of Compensation
Payment/Tax Withheld
Republika ng Pilipinas
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas
For Compensation Payment With or Without Tax Withheld
Fill in all applicable spaces. Mark all appropriate boxes with an "X"
1
For the Year
2015
( YYYY )
Part I
Employee Information
3 Taxpayer
Identification No.
156
351
031
4 Employee's Name (Last Name, First Name, Middle Name)
0000
101
6 Registered Address
6A Zip Code
6B Local Home Address
6C Zip Code
6E Zip Code
7 Date of Birth (MM/DD/YYYY)
8 Telephone Number
9 Exemption Status
Single
2316
July 2008 (ENCS)
For the Period
From (MM/DD)
To (MM/DD)
Details of Compensation Income and Tax Withheld from Present Employer
Part IV-B
Amount
A. NON-TAXABLE/EXEMPT COMPENSATION INCOME
5 RDO Code
SEBLERO, DOLORES MEJIA
6D Foreign Address
BIR Form No.
32 Basic Salary/
Statutory Minimum Wage
32
Minimum Wage Earner (MWE)
33 Holiday Pay (MWE)
33
34 Overtime Pay (MWE)
34
35 Night Shift Differential (MWE)
35
36 Hazard Pay (MWE)
36
37 13th Month Pay
and Other Benefits
37
38 De Minimis Benefits
38
0.00
39 SSS, GSIS, PHIC & Pag-ibig
Contributions, & Union Dues
39
4,221.00
40 Salaries & Other Forms of
Compensation
40
0.00
41 Total Non-Taxable/Exempt
Compensation Income
41
9,221.00
5,000.00
Married
9A Is the wife claiming the additional exemption for qualified dependent children?
Yes
10 Name of Qualified Dependent Children
No
11 Date of Birth (MM/DD/YYYY)
(Employee share only)
12 Statutory Minimum Wage rate per day
12
13 Statutory Minimum Wage rate per month
13
14
Minimum Wage Earner whose compensation is exempt from
withholding tax and not subject to income tax
Part II
Employer Information (Present)
15 Taxpayer
Identification No.
005
869
215
0000
16 Employer's Name
SAINT THERESE DE AVILA LEARNING
17 Registered
Address
17A Zip Code
CENTER,
INC.
#0047-B MIGUEL OBACH
9200
Main Employer
Secondary Employer
POBLACION
LONE DISTRICT
LDN
Part III
Employer Information (Previous)
ILIGAN CITY
LDN
18 Taxpayer
Identification No.
19 Employer's Name
20 Registered Address
20A Zip Code
Part IV-A
21 Gross Compensation Income from
Summary
21
Present Employer (Item 41 plus Item 55)
22 Less: Total Non-Taxable/
22
Exempt (Item 41)
23 Taxable Compensation Income
23
from Present Employer (Item 55)
24 Add: Taxable Compensation
Income from Previous Employer
25 Gross Taxable
Compensation Income
26 Less: Total Exemptions
24
27 Less: Premium Paid on Health
27
25
26
and/or Hospital Insurance (If applicable)
28 Net Taxable
Compensation Income
29 Tax Due
28
29
30 Amount of Taxes Withheld
30A Present Employer
30A
30B Previous Employer
30B
31 Total Amount of Taxes Withheld
As adjusted
60,000.00
9,221.00
60,000.00
60,000.00
75,000.00
0.00
0.00
0.00
B. TAXABLE COMPENSATION INCOME
REGULAR
42 Basic Salary
43 Representation
44 Transportation
60,000.00
43
44
45 Cost of Living Allowance
45
46 Fixed Housing Allowance
46
47 Others (Specify)
47A
47A
47B
47B
SUPPLEMENTARY
48 Commission
48
49 Profit Sharing
49
50 Fees Including Director's
Fees
50
51 Taxable 13th Month Pay
and Other Benefits
51
52 Hazard Pay
52
53 Overtime Pay
53
0.00
54 Others (Specify)
54A
54A
54B
54B
55 Total Taxable Compensation
Income
31
42
55
60,000.00
We declare, under the penalties of perjury, that this certificate has been made in good faith, verified by us, and to the best of our knowledge and belief, is true and correct
pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof.
Date Signed
56
Present Employer/ Authorized Agent Signature Over Printed Name
MARY JOY P. PATALINGHUG
CONFORME:
57
CTC No.
of Employee
DOLORES MEJIA SEBLERO
Employee Signature Over Printed Name
Place of Issue
Date Signed
Amount Paid
Date of Issue
To be accomplished under substituted filing
I declare, under the penalties of perjury, that the information herein stated are reported
under BIR Form No. 1604CF which has been filed with the Bureau of Internal Revenue.
58
MARY JOY P. PATALINGHUG
Present Employer/ Authorized Agent Signature Over Printed Name
(Head of Accounting/ Human Resource or Authorized Representative)
I declare,under the penalties of perjury that I am qualified under substituted filing of
Income Tax Returns(BIR Form No. 1700), since I received purely compensation income
from only one employer in the Phils. for the calendar year; that taxes have been
correctly withheld by my employer (tax due equals tax withheld); that the BIR Form
No. 1604CF filed by my employer to the BIR shall constitute as my income tax return;
and that BIR Form No. 2316 shall serve the same purpose as if BIR Form No. 1700
had been filed pursuant to the provisions of RR No. 3-2002, as amended.
59
DOLORES MEJIA SEBLERO
Employee Signature Over Printed Name
