ANNEX “B 2” -

INCOME PAYEE'S SWORN DECLARATION OF GROSS RECEIPTS/SALES

(ForScJf-Employed and/or Engaged in the Practice of Profession with Lone Income Payor)

A. '
” ’' Tmptftb > of legal age, -single/ married to
Mm. *
: CMiseurvjip/

permanently residing at
< Xante of Spotarj

v . with
Taxpayer Identification Number (TIN ) after having been duly sworn in accordance with law
hereby depose and states :

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with Taxpayer Identification Number ${t

: bteisiyrf
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^ and business address at
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2. That for the current year , my gross receipts will not exceed Two Hundred Fifty Thousand Pesos (P250.000.00) and
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that I am registered as a non VAT taxpayer; that whatever is the amoujit of income received, I will comply with the
requirement to file my Income Tax Return on the prescribed due date. For this purpose, I opt to avail of either one of the
following:

Graduated Income Tax Rates under Section 24( A )(2 )(a) of the Tax Code, as amended, based on the taxable
income. With this selection , I acknowledge that I am subject to 0% income tax, thus, not subject to
creditable withholding tax; subject to percentage tax , if applicable, and will file the required percentage tax
returns or subject to withholding percentage tax, in case of government money payments.

S3" Eight Percent (8%) income tax rate under Section 24( AX2)( b) of the Tax Code, as amended, based on
-
gross receipts/sales and other non-operating income with this selection, I understand that this is it ) lieu of
the graduated income tax rates and the Percentage Tax under Section 116 of the Tux Code, as amended;
thus, no withholding tax shall be made;

3. -
That based on my selection above, if my gross saics/teeeipts and other non operating income exceeds P 250,000.00 but not
.
ova- P3.000 000.00, myaftvre-stated lone income payor shall automatically withhold the prescribed rate of will) holding tax:
a. In case of Graduated Income Tax Rates, I acknowledge that aside from income tax, I am subject to
business tax (Percentage Tax, if applicableitmd creditable withholding of income in excess of P250,000,00.
and business tax withholding, if any. are applicable on me entire income payment; OR
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b. In case of Eight Percent (8%) income tax rate, 1 acknowledge that I am only subject toincomc tax and thus,
to the creditable withholding income tax in excess of P250.000.00;

4. That 1 duly execute this SWORN DECLARATION in compliance with the requirement prescribed under Section of
Revenue Regulations No. ;

5. That I declare, under the penalties of perjury, that this declaration has been made in good faith, and to the best of my
knowledge and belief to be hue and correct. "' '
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IN WITNESS WHEREOF, l have hereunto set my hand this ”
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day of ^ rtf ' t'5 't - . f' ft? del ,
Philippines
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Stfl!a'ainJJrPt:MldXatiircfh:ifislifmtraX!mTr
JAN 0 4 2022
SUBSCRIBED AND SWORN to before me fit is day of a « g i.. 0 t »5 C I T t
Applicant exhibited to me his/ her issued on

A T 1 Y , N /iRlA
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Date Received: . RccdivdiTM itf c >: ais! m -ca*
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(MM DDr YYYY OVOOI ) -
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UertpKi!ftwftaigon of ttaiwrxd Officer

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(to be fifed up the BIR)

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Republika tig Pilipinas
SIR Form No .
El Kagawaran ng PananaJapi
Kawanihan ng Rentas Intemas
.
Payment Form 0605Juiy 1999 (ENCS)

Fill in all applicable spaces. Mark all appropriate boxes with an "X”

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Stamp of Receiving
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From Audit/invesfigaticm/ Office

Deliquent Accounts and Date Of Receipt
S t declare, under the penalties of perjury, that this document has been
APPROVED BY:
made in good faith, verified by me, and to the best of my knowledge and
belief is true and correct, pursuant to the provisions of the National
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Internal Revenue Code, as amended, and the regulations issued under

authority thereof.
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Signature over Printed Namte ^
Signature over Printed Name of Ta jayer/auihotKeoTwpreseraatlve TifieiPositioniJif Signatory Head of Office
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Particulars j Drawee Bank/Agency
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Machine Validation/Revenue Official Receipt Details ( if not filed with the bank )

Taxpayer CiasaBcston: l - Individual M - NofHndlvIdual

(To [Link] up fay SIR) OLN: i

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Republic of the Philippines
Department of Finance
Bureau of internal Revenue

POT Self Employed (Single Proprietor/ProfessionsT},

Mixed income Individuate, Non-Resident Alien
Engagon In Trade/Busmass. Estate and Trust
Application for Registration

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SIR Form No.

1901
January 2018(£NCS)

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1 PhilSys Number (PSNj
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B .GfenderJ tefe G Female j 9 Ovi] Status D Single~ Q Married

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17 Business Address iK
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18 Foreign Address cuST ilStWEff -

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19 Municipally Ooite fj • 2& PtiijS«[Link] !pMioii BT m 9R
(To o# Stfod up by SIR)
21 Idontil * . iv
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xssmm. issuer . -
p:'«Pi>'Qr-»nt'y nit iesue

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»: Preferred Contact Type __
[>l Mobile Number
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Fax Number Email Address (mqutrad)

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24 Employment Status of Spouse QEm^yed Abroad [ jEngaged in BusinessJPraciica of Profession

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32 Local Residence Address

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34 Singfe Business Number
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35 Pnriiaiy/Seooridar
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Primary
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ina JStiy. | Business Registration Number Un® of Business , fj m
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37 Details of Registration / Accreditation
37A Registration / Accreditation Number
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37B Sfoctfeity Date MrESWyOJ ''
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370 Registered Activity

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38 Facility Details <l» Piai» fc»Prod«eteyia!t; SP
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40 Authority to Print Receipts am invoices j
40A Printer's Name

40G Printers Accreditation Number

406 Registered Address
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40B Printer’s TIN
AQD Date erf Accreditation ( KmocPirrf )
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40H Manner of Receipt/lnyotces | j . Bound '

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401 Descriptions of Receipts and Invoices (Adnitiomi Sh'zet s if

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pte EmpI
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^ Multiple Empjoyments) Within the Calendar

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41AName of Hfnpioypr T 41B TIN of employer Sp

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41C Name of Employer ] 4.1ft UN of Employer J
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42 Declaration
i dectere, unto the panaWos of peijury, that this application has been mada In good feish, vurtfiad by m are So!i» bast of my tawtedge and baSef, is tee aid correct, pureaaw to me provisions at the MaSonel
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intend Revanus Cods, as amended, and the regulations issued imdsr the authority Stored?. Further I give my consent to the processing of my information a* contemplated under the *0 Privacy Act of 2012 (RA.
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No 103733 forlsgitlmatewx!lawful purposes.

Taxpayw/Avthorized Reproseniafive
( Signature oyer Printed Hams)

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PartViH PrimaryfCumgntEmployer Information
f ] HwdOflfcfe . |~ ] Office
43 Type of Rogistorad Office
~ Blanch~~
. Big j118 F-i Vi I f i.l 45 R£)0Cade J I
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46 Employer Name If indlviduar ( Last Nam ) | - fffaMifeirtar r " mmeHarnf

IfNonrfrtdlvidtial . (Registered Netm; yy , .,

47 EmptoyarAddrsss
fieWfayWM»«Bicr •
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48 Contact Details EC;

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49 Reiationsblp Start Date JLJ r ! r : j

^ 0 Municipality Code ~c
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Stomp of SIR ReoPMng Offho
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) declare « ef the pwaMes of perjury, that appfcaSon has teen me in psd vsrifietf by me sod ia tte best o!my knawteitge end belief, is ffue end
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cotred pursuant to »e provisions of the totiwa!IntomatRavenusCode, as amended, and the reguliifcns asued undar authority Ihemof. further, I giva my consert
to the processing of my jnformatton asmoletraiMeduwlerSia ' ta Privacy Ad of 2012 (R.A NO. ?0i?3!for tofftate and Israi&t purpose : i : .
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eMPlOYER/AUTHORIZHDREPKfc&trr imnt.
(Signature - -
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Part IX Payment Details -
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52 For trie Yeaar
55 TaxTypa
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53 Date of Payment twmrfrm
56 Manner erf Payment
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REGISTRATION FEE
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57 Type of Payment
| 54 ATC
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— i FULL PAYMENT
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58 Registration Fee
59 BiR Printed Receipts / Invoices
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