SWORN DECLARATION OF GROSS SALES

Republic of the Philippines )

Province of Romblon )
Municipality of Odiongan )

I, ____________________________________, of legal age, _____________ (Civil Status), residing at

__________________________________________ and operator/owner of
________________________________________________( name of registered business establishment), after
being sworn in accordance with law, depose and say that:

1. I receive professional / talent / service fees / gross revenue as ________________________

(please check box/es) and indicate amount:

 Practice of Profession ___________  Retailer of Essential Commodities ____________

 Retailer of Non-essential Commodities ___________  Non-profit/Cooperative/Educational ____________
 Contractor/Independent Contractor ___________  Dormitory/Boarding House Operator ___________
 Other Kinds/Independent Contractor __________  Real Estate Lessor ____________
 Banks/Other Financial Institution ___________  Miller/Grinder of Essential Commodities _________
 Retailer of Liquors/Wine/Spirits ___________  Retailer of Cigarette/Tobacco ____________
 Wholesaler of Liquors/Wine/Sprits ___________  Wholesaler of Cigarette/Tobacco ____________
 Wholesaler/Dealer/Manufacturer of Essential Commodities ______________
 Wholesaler/Dealer/Maufacturer of Non-Essential Commodities ______________
 Proprietor/Operator of Amusement Place/Devices ______________
 Others: Specify:________________________________________ ______________

2. I am executing this declaration as a requirement for securing my business/mayor’s permit.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________,2020, in the municipality of
__________________________, province of _____________________, Philippines.

Affiant – Declarant
TIN:_______________

SUBSCRIBED AND SWORN to before me in _____________, this ______ day of ___________________

with Community Tax Certificate number: ________________, issued at __________________________, on
________________, 20___.

___________________________
Administering Officer