____________________ ) SS.


I, ______________(Name of Self-Employed Professional), Filipino, of legal
age, single/married with office address at ____________________
_____________________________, after having been duly sworn in accordance with
law, hereby depose and say:
1. That I am a __________( Profession ) with TIN #______________, duly
registered with the Bureau of Internal Revenue under RDO ___;
2. That as a __________( Profession ) , I render professional services to a
number of clients, and that my fees range from ___________ to
___________ (ex.P1000.00 – P5,000.00 or 3%-5% of gross selling price );
3. That, I bill my clients by issuing them, Official Receipt/s that are duly
registered with the BIR;
4. That, the factors I consider in determining the equitable rate of fees charged
or to be charged are: the complexity of the work performed or to be
performed, the extent of responsibility assumed, the volume of work – number
of hours spent or to be spent in doing the work and _________
5. That this affidavit is hereby executed to attest to the truth of the facts above-
stated, and in compliance with the dictates of BIR Revenue Regulations No.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
____________, 2014 at ______City, ___________ Province, Philippines.


SUBSCRIBED AND SWORN to before this____________ day of
______________, in ____________, affiants exhibiting to me his/her
____________________________Issued at _____________________
Page No.
Book No.
Series of 2014

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