Annual Information Return of BIR Form No.

Creditable Income Taxes Withheld

Republika ng Pilipinas
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas
 1   For the Year (YYYY) 2019
1604-E
(Expanded)/Income Payments
July 1999 (ENCS)
Exempt from Withholding Tax
 2   Amended Return?  3   No. of Sheets Attached? 0

        Yes    No    
   Part I Background Information
 4 TIN  203 139 533 000  5 RDO 003  6  MERCHANDISING
Code  Line of Business/Occupation 
Withholding Agent's Name (Last Name, First Name, Middle Name for Individuals) / (Registered Name for Non-  8 Telephone Number
 7 Individuals)
09455979308
  COSTALES., JR ANTONIO STA ANA

 9 Registered Address  10 Zip Code

  BANGAOILAN BANGAR LA UNION 2519

 11 Category of Withholding Agent Private     Government

   Part II S u m m a r y   o f   R e m i t t a n c e s
   Schedule 1 R e m i t t a n c e   p e r   B I R   F o r m   N o.   1 6 0 1 - E
DATE OF NAME OF BANK/BANK TOTAL AMOUNT
MONTH CODE/ROR NO., IF ANY TAXES WITHHELD PENALTIES
REMITTANCE REMITTED
JAN 2/8/2019 UCPB 250.00 0.00 250.00

FEB 3/8/2019 UCPB 250.00 0.00 250.00

MAR 4/30/2019 UCPB 250.00 0.00 250.00

APR 5/6/2019 UCPB 750.00 0.00 750.00

MAY 6/7/2019 UCPB 500.00 0.00 500.00

JUN 7/30/2019 UCPB 250.00 0.00 250.00

JUL 8/13/2019 UCPB 2,551.35 0.00 2,551.35

AUG 9/10/2019 UCPB 2,660.83 0.00 2,660.83

SEP 10/30/2019 UCPB 5,833.91 0.00 5,833.91

OCT 11/11/2019 UCPB 3,776.07 0.00 3,776.07

NOV 12/10/2019 UCPB 3,908.33 0.00 3,908.33

DEC 1/31/2020 UCPB 23,329.86 0.00 23,329.86

TOTAL 44,310.35 0.00 44,310.35

   Schedule 2 R e m i t t a n c e   p e r   B I R   F o r m   N o.   1 6 0 6

DATE OF NAME OF BANK/BANK TOTAL AMOUNT
MONTH CODE/ROR NO., IF ANY TAXES WITHHELD PENALTIES
REMITTANCE REMITTED
JAN 2/8/2019 UCPB 250.00 0.00 250.00

FEB 3/8/2019 UCPB 250.00 0.00 250.00

MAR 4/30/2019 UCPB 250.00 0.00 250.00

APR 5/6/2019 UCPB 750.00 0.00 750.00

MAY 6/7/2019 UCPB 500.00 0.00 500.00

JUN 7/30/2019 UCPB 250.00 0.00 250.00

JUL 8/13/2019 UCPB 2,551.35 0.00 2,551.35

AUG 9/10/2019 UCPB 2,660.83 0.00 2,660.83

SEP 10/30/2019 UCPB 5,833.91 0.00 5,833.91

OCT 11/11/2019 UCPB 3,776.07 0.00 3,776.07

NOV 12/10/2019 UCPB 3,908.33 0.00 3,908.33

DEC 1/31/2020 UCPB 23,329.86 0.00 23,329.86

TOTAL 44,310.35 0.00 44,310.35

        I declare, under the penalties of perjury, that this return has been made in good faith, verified by me, and to the Stamp of Receiving
Office
best of my knowledge and belief, is true and correct, pursuant to the provisions of the National Internal Revenue
and Date of Receipt
Code,
as amended, and the regulations issued under authority thereof.
 
 
12_____________________________________________ 13_______________________________
Taxpayer/Authorized Agent Signature over Printed Name Title/Position of Signatory
     
Submit