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ANNEX C BIR Form No.

______
PRDM No. : Date :

Republic of the Philippines DEPARTMENT OF FINANCE BUREAU OF INTERNAL REVENUE

PRODUCT REPLENISHMENT DEBIT MEMO


Large Taxpayers Service Excise Group 2/F, Rm. 216 A & B, BIR National Office Diliman, Quezon City

Attention
Sir/Madam:

Head Revenue Executive Assistant LTS- Excise Group

We have authorized the debit of product replenishment on excisable articles pursuant to Revenue Regulations No. _________ in relation to Section ___ of the National Internal Revenue Code, detailed as follows: Product Description/Brand Name/Model
Volume

Quantity
Unit of measure

Excise Tax Due P

TOTAL COMPANY NAME TIN Assessment No. Volume/Amount of product replenishment tax debit Amount available as of date of utilization Amount of product replenishment tax debit Balance as of date REFERENCE: PRC No. Date Issued Date revalidated Original Amount No. and date of last PRDM issued Purpose : Approved: : : : : : :

: : :

RecommendingApproval: Division Chief LT- Field Operations Division

Head Revenue Executive Assistant Large Taxpayers Service Excise Group

Note: This PRDM is valid within thirty (30) calendar days from issuance hereof and subject to liquidation within forty five (45) calendar days upon transmittal. Any erasure shall render this PRDM invalid. Furthermore, this PRDM is being issued against the subject PRC on the basis of the remaining balance of the said PRC as evidenced by the entries, if any, posted at the subject PRCs dorsal portion. Final acceptance of this PRDM for product replenishment shall, however, be based on the PRCs actual creditable balance as verified by the accepting office.

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