► DLN:

Republika ng Pilipinas Certificate of Compensation B!R Form No.

UkiSltii) Kagawaran ng Pananalapi

Kawanihan ng Rentas Internas Payment/Tax Withheld 2316
For Compensation Payment With or Without Tax Withheld July 2008 (ENCS)

Fill in all applicable spaces. Mark all appropriate boxes with an "X
1 For the Year For the Period
*' From (MM/DD) rtiii To (MM/DD)
(YYYY) ►
Part I Employee Information Part IV-B Details of Compensation Income and Tax Withheld from Present Employer
3 Taxpayer Amount <- ,
Idenyfication No. A. NON-TAXABLE/EXEMPT COMPENSATION INCOME
4 Employee's Name (Last Nam&.;Fil;^ Name, Middle Name). 5 RDOCode
32 Basic Salary/
FORTUSf KOSBLUE ADAMTB Statutory Minimum Wage 0.00
Minimum Wage Earner (MWE)
6 Registered Address ^ '• 6A Zip Code
33 Holiday Pay (MWE)
0.00
6B Local Home Address 60 Zip Code ■li- JK.v -izyii"'. :'.-;:nkvv
34 Overtime Pay (MWE) 0.00 I
6D Foreign Address 35 Night Shift Differential (MWE) 35

7 DateofBjfth:(MM/DD/YYYY) 8 Telephone Number 36 Hazard Pay (MWE) 0.00

.» : L.- I i ...WB,

Q pypmntinn Status 37 13th Month Pay 84,635.50

I I Single I V I Married and Other Benefits
9Als the wife claiming the additional exemption for qualified dependent children? 33 De Minimis Benefits 17,181.75
Yes rn No
10 Name of Qualified Dependent Children ^ 11 Date of Birth (MM/DD/YYYY)
39 SSS, GSIS, PHIC & Pag-ibig 39
Contributions & Union Dues 9,493.90
(Employee share only)

40 Salaries & Other Forms of

Compensation 0.00
12 Statutory Minimum Wage rate per day 12|^
j41 Total Non-Taxabie/Exempt
13 Statutory Minimum Wage rate per month 13r ; Compensation Income 111,311.15
141 I Minimum Wage Eamer whose cornpensation is exempt from
' ' withholding tax and not subject to Income tax . ■ B. TAXABLE COMPENSATION INCOME
REGULAR

42 Basic Salary
364,684.10
16 Employer's Name ; 525
43 Representation
.jEHERGY DEVELOPMENT CORPORATION 0.00
44 Transportation

45 Cost of Living Allowance

: ry\ Main Employer 0.00
part III Employar Informatiori (Previous
18 Taxpayer 46 Fixed Housing Allowance
Identification No. ►
19 Employer's Name 47 Others (Specif
47Ai

20 Registered Address

SUPPLEMENTARY
Part IV-A 48 Commission
21 Gross Compensation Income from 21 564,801.69
Present Employer (item 41 plus item 55)
22 Less- Total Non-Taxable/ 111,311.15 49 Profit Sharing
Exempt (Item 41)
23 Taxable Compensation Income 50 Fees Including Director's
from Present Employer (item 55)
0.00 Fees
24 Add- Taxable Compensation
Income from Previous Employer
25 Gross Taxable 453,490.74 51 Taxable-ISth "Month Pay
Compensatton Income and Other Benefits
26 Less: Total Exemptions 0,00 52 Hazard Pay
27 Less' Premium Paid on Health 0.00
and/or Hospital Insurance (If Applicable) 53 Overtime Pay
S?enfJ§on income 453,490.74
29 Tax Due 43,372.68 54 Others (Specifv)
54AI ^—~
43,373.00 86,606.64
30 Amount of
30A Present Employer
308 Previous Employer 0.00

31 Total Amount of Taxes Withheld 31 55 TotalTaxable Compensation 55 453,490.74

Income
As adjusted
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 NatioMl^emaU^evenue Code, as amended, and the regulations issued under authprify thereof.
Date Signed I
Present Employer/j^jthorized Agent Sig^ture Over Printed Name
CONFORME:
aQg8U,a A. FQRfUS
Date Signed'
Employee Sigr^ature Over Printed Name Amount Paid
CTCNo. [ I Piace of Issue I
Date of issue
of Employee
To be accomplished under substituted filing —
";nj^under the Pen?'"®.® information herein staled are reported I declare under the Derrallies of perjury that I am qualified under substituted filing of
mdir BIR Fo'"'" '"'®^Fal Revenue. Income Tax Returns (BIR Form No. 1700), since I received PUfelV
jf y- § from onlywithheld
correctly one employer In the Phils,
by my employer (taxforduetheequals
calendar ye®r, hatthat
tax withheld), taxes^ehave
B Fbeenm
No- 1604CF fiied by my employer to the BIR shall constitute as my Income lax return
2316 shall serve the same purpose as if BIR Form No. 1700
SKILX S . Vt]0)8 had been filed pursuant to the pfoVisions of RR 3-2002, as amended.
/ M&UoIt A. FOBWS
58 r-^nl Employer/Authorized Agent Signature Over Printed Name u-
-ij frf or
(Head nf muuv
Accounting/Human
a Resource or Authorized Representative) , . —Name
EmnlnvAP .Rinnature Over Pnnted