Republic of the Philippines

:or BIR BCS/ Department of Finance Anngx "'B'"

lse Item: Bureau of lnternal Revenue

Acceptance Payment Form

0621-DA Tax Amnesty on Delinquencies
Pursuant to Republic Act No. 11213 ilffiffir#t$t
information in CAPITAL LETTERS usinq ELACK ink Mark all

1.DaIe FiIe MT/DNYYYY) 2,Tax:Type 4 Naimbei of,SheeVa Attached

P.art I : Taxpayer rlnformation

5 Taxpayer ldentification,Number (I/N)
71 ,Name ftasf Name, First Name,:Middle Name for,lndividualOR Registered'Namefor

address. lftiardi, irrb#fEbE rdr-€iiress ffi€,s}*,edaddBssit dftrcr{lto't'fi}eond,f€dCress' g0bf}e RDOb

8A'ZtP,Code

Pad ll - Tax Amount : :.' ',.,.:::r:.:,:

10 TaxAmnesty Amount [Lifted from Tax Amnesty Retum (btR Form No. 2118-DA)]
that this certificate has b€en mde in good faith;,verifed by ine/us;'and to lhe
of my/out, knoli ard, belref';,is true.;aM. conect :pursuantth ltre ,poviSons oJ the National lntemal Revenue Code, as
ldga For payment of Tax Amnesty on Delinquei',ci :s
amended.and,tha reguialions:lssued tndelaithodty het*1' purtrei, lr\ro give:qry.colsent'to &e.,processing ol my/ou|
informatjon ai contemplated under the
*Data PrlvacyAd of 2012 (R.A. No. 10173) br legitimate and lawful purposes. ENDORSED BY:

For lndividual:

Signature over Printed Name'of Taxpryer/Auhori2ed Signahrre over Printed Name of.PresidenWice PiesidenV
Representativeff ax Agent . :'Authorized0fficeror,Replesentativellax{gent
. ' (indicate tille/dxignation aN.TtN) ,"',:'. ::.:.'.,(indicatetifreldesignation
.
andTIN)' ": ;:;-:',
Reven ue D istrict,Officer
over'Pinted
Part lll.;'DetailS

Machine Validation/Revenue Official Receipt Details (if not filed with an Authorized Agent Bank) Stamp of Receiving Office/AAB and Date of Rc,c:.:pi
(RO's Signature/Bank Tellels lnitial)

:The BIR a Privacy Policy is in the BIR website (www.bir.gov.ph)

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