SWORN DECLARATION

Date___________, 20___

NAME OF TAXPAYER:

ADDRESS:

TAX IDENTIFICATION NUMBER:

CLASS OF PROFESION/CALLING:

CERTIFICATION

This is to certify that in accordance with the REVENUE REGULATIONS NO.

30-2003, I am receiving an Annual gross professional income of less than the amount of
SEVEN HUNDRED TWENTY THOUSAND PESOS (P 720,000.00) and that, I am
executing this Declaration for purposes of determining the rate of withholding tax to be
deducted against my professional income.

______________________
Signature

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES )

City/Municipality of______________ ) S.S.

BEFORE ME, a Notary Public, in and for the above jurisdiction, this
_____,Day of _____________, personally came and appeared with
_____________________ issued on ____________ at ____________ known to me
and to me known to be the same person who executed the foregoing instrument
which he/she acknowledge before me as his/her free voluntary act on deed.

WITNESS MY HAND AND NOTARIAL SEAL on the date and at

the place first above written.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of _____ .