Annex "C"

SWORN DECLARATION

REPUBLIC OF THE PHITIPP]NES

PROV]NCE OF
CIfY/MU NICIPALITY OF

l, lNome af Authorized Representotive), \Notionolitv), of legal age desiSnated as (Postior) of

(Reoistered Nome of componv/Cotporotion), with business address located at
do herebv certify the follow ng:

- That in compliance with the reqLrlrements of Revenue Regulations No.-, submltted

herewith is/are (Nurnber of DVD R/s) containing lllllbei--ql j!3M!L--ElB_lEPlE
2307/2316) covering the period mm/dd/wv.

z That the contents of the DVD-Rs being submitted herewith conform to the
conditions/specification requirements set by the Bureau of lnternal Revenue.

- That the soft copies of the BIR Form 2307/2316 contained in the DVD-R/S being submitted
herewith are the complete and exact copies of the original thereof.

I HEREBY DECLARE UNDER THE PENALTIES OF PERJURY THAT THE FOREGOING

ATTESTATIONS ARE TRUE AND CORRECT.

Name and signature of Authorized

Representative
TIN:

SUBSCRIBED and sworn to before me, in the City/Municipallty of this day

of _, 20_ by with Residence Certificate No. issLred at
al 2a

Notary public 0l' lNlliliN/J RrlE)arn

BURIAU
Doc. No. RECORDS MGT. NIVISION
Pag-. No.
Book No.
{t} r, r 206
Serles of
0t ? a lnt
R.ECEtrVED
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