Republic of the Philippines ) Annex “B”

_______________________ ) S.S.

SWORN DECLARATION OF
NO PROTEST/WITHDRAWAL OF PROTEST FILED

I, (name of authorized representative), of (name of company), Filipino, of legal age and a

resident of __________________________________________, after having been sworn to in
accordance with law, hereby depose and say:

1. That I am the (company designation) of (company name) with business address at

(company address) and Taxpayer Identification Number (TIN) __________________
registered RDO/LTD No. _______;

2. That, on behalf of the (company name), I am duly authorized to apply for Tax Amnesty
on Delinquencies pursuant to Republic Act No. 11213 as implemented by Revenue
Regulations (RR) No. 4-2019, for taxable year/s __________;

3. That assessment notice was issued with the following details:

DATE FINAL ASSESSMENT TAXABLE TAX TYPE AMOUNT BASIC
ISSUED NOTICE (FAN) NO. YEAR TAX ASSESSED

4. That I hereby attest that:

[ ] NO PROTEST was filed within 30 days from receipt of the FAN with any office of
the Bureau of Internal Revenue (BIR) in relation with the above mentioned assessment/s
notice/s.

[ ] a PROTEST was filed on ____________________, but the same was WITHRAWN

on ____________________, before the effectivity of RR No. 4-2019;

5. That accordingly, the said tax liabilities became delinquent on or before the effectivity of
RR No. 4-2019;

6. That I attest to the truth of the foregoing facts for the purpose of availing the Tax
Amnesty on Delinquencies.

In witness hereof, I have hereunto affixed my signature this ________ day of

______________, 20__ at ______________________________, Philippines.

Signature over Printed Name

Affiant

SUBSCRIBED AND SWORN to before me this ________________ at

_________________. Applicant exhibited to me his/her (Government issued ID and No.) issued
at ___________________ on ___________________.

Notary Public
Doc. No._____
Page No._____
Book No._____
Series No._____