AFFIDAVIT – DECLARATION

OF CURRENT YEAR’S GROSS INCOME

Republic of the Philippines )

Province of ___________________)
City/Municipality of ____________)

I, _______________________ also known as ___________________, of legal age,

single/married, residing at _______________________________________after being sworn in
accordance with law, depose and say that:

1. I receive professional / talent / service fees as _____________________________

(please check box/es):

/ / Practice of Profession / / Management & Technical Consultants

/ / Professional Entertainment
/ / Professional Athlete
/ / Director
/ / Others: Specify __________
/ / Bookkeeping agents and agencies
/ / Other recipients of talent fees
/ / Director who is not employee of the
company
/ / Judicial person in the practice of
profession

2. As such, I have received a gross income of P____________________ for the

current year as of _________________.

3. I am executing the Affidavit-Declaration as a requirement of Revenue

Regulations No. 30-2003 of the Bureau of Internal Revenue in the determination
of the applicable creditable withholding tax rate (10% or 15%) to be imposed by
withholding agent/s.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of

______________, in the Municipality of______________ province of ______________
Philippines.

Affiant – Declarant
TIN: ___________

SUBSCRIBED AND SWORN to before me, in ______________, this _____ day

of _________________ with Community Certificate No. _______________ issued at
_________________ on ______________, 20____.

Doc. No. _______

Page No. _______
Book No. ______
Series of 20_____