DLN:

REPUBLIC OF THE PHILIPPINES

BIR Form No. Appl
DEPARTMENT OF FINANCE

BUREAU OF INTERNAL REVENUE Philippine Tax Convention with 0901 From

January
(Name of Contracting State) 2004

Fill in all applicable spaces. Mark all appropriate boxes with an "x"
1 Relief Requested
Exemption Treaty Rate Date: ________________________

Part I RECIPIENT OF INCOME

2 Name: TIN:
(if applicable)
Prinicipal Address:

3 Authorized Local Representative to file this application:

Name: TIN:
(if applicable)
Address:

4 Permanent Establishment (for an enterprise) Fixed Base (for an individual) in the Philippines, if any:

Name: TIN:
Address:

Part II WITHHOLDING AGENT

5 Name: TIN:

Address:

6 Nature of Income

Business Profits Dividend Royalty Other: Please specify:

Profits form Shipping and Aircraft Interest Income from personal services

Part III DECLARATION UNDER PENALTIES OF PERJURY

Stamp of BIR-ITAD
Receiving Office and Date of
I/We declare, under the penalties of perjury, that this application and the representations therein Receipt
have been made in good faith, thay they have including the accompanying documents have been verified
by me/us and to the best of my/our knowledge, belief, and information are true, correct, and complete.

(Signature of Applicant/Representative over printed name) Title/Position of Signatory

This application form is to be filed with the International Tax Affairs Division
Room 811, 8th Floor, BIR National Office Building, Diliman, Quezon City
Application For Relief
From Double Taxation
 Application For Relief
Republika ng Pilipinas Application for Certificate
From Double Taxation of BIR Form No.

1945
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas Tax Exemption
RP Tax for
Convention with

Cooperatives
For Cooperatives registered under Republic Act No. 9520 Version 1.0 August 2010

Please check Original Renewal

RDO Filing Reference No. /
Document Locator Date of Application
1
Part I BACKGROUND INFORMATION
Fill in all applicable spaces. Mark all appropriate boxes with "X" or with "NOT APPLICABLE" if no appropriate response.

2A Cooperative Identification Number (issued by the CDA)

2B Date of CDA Registration

3 Taxpayer's Taxpayer's Identification Number
Name 3A 3B

4 Business 4
Address
No. (Include Building Name) Street District/Municipality City/Province Zip Code

5 Business 5A 5B 5C
Phone Number
Area/Access Code Telephone Number Fax Number

Part II BUSINESS STRUCTURE

6 Type of
Cooperative

7 Main Line of
Business

8 Extent of 8A Members 8B Both Members and If 8B is marked, items 9 and 10 should be filled-up.
Transaction Only Non-Members

9 Accumulated Reserve and

Undivided Net Savings 9A Not more than 9B
Ten (10) Million pesos in the amount of
State actual amount
9C More than 9D
Ten (10) Million pesos in the amount of
State actual amount
10 Share Capital
Contribution 10A P15,000 or less per member 10B More than P15,000 per member

PART III UNDERTAKINGS AND COVENANTS

11
1. That the cooperative was issued a Certificate of Good Standing by the Cooperative Development Authority on .
2. That at least twenty-five percentum (25%) of the net income is returned to the members in a form of interest and / or patronage refunds.
3. That the cooperative has applied for an update of BIR Registration as a condition to the processing of this application.
4. That the cooperative has not filed any similar application or request for exemption with any other office of the Bureau of Internal Revenue.
5. That the matters presented in this Application are not identical to any application being considered or examined by the Bureau of Internal
Revenue or is involved in any pending administrative appeal or court litigation or is pending in any other government agency.
6. That the undersigned is executing this Application in accordance with the provisions of the Joint Rules and Regulations Implementing
Articles 60, 61 and 144 of Republic Act No. 9520 and Revenue Memorandum Order No. _________ dated __________.
7. That the undersigned declares under penalties or perjury, that he/she has examined this request, including the accompanying documents as
required herein, and to the best of his/her knowledge, belief and information, the facts presented in support of this request for
Certificate of Exemption are hereby true, correct and complete.

Stamp of BIR Receving Office and

Date of Receipt
Signature of Applicant/representative over printed name

Title / Position of Signatory

Back page of BIR Form 1945

Part IV DOCUMENTARY REQUIREMENTS

Basic Documentary Requirements [For Original Issuance of Certificate of Tax Exemption]
1 Certified True Copies of the Articles of Cooperation and By-Laws, as certified by the Cooperative
Development Authority (CDA) ;

2 Certified True Copy of the new Certificate of Registration issued by the CDA under the new
Cooperative Code, as certified by the CDA;
3 Certified True Copy of the current Certificate of Good Standing issued by the CDA, effective on date of
application; and

4 Certified True Copy of the BIR Certificate of Registration of the Cooperative.

Additional Documentary Requirements

1 Original Copy of Certification under Oath of the List of Cooperative Members with their respective
Taxpayer Identification Number (TIN) and their capital contributions prepared by authorized official of
the Cooperative. For the initial submission of this list of cooperative members, those without TIN may
temporarily use NSO number or other government issued ID number or Community Tax Certificate
Number.

Basic Documentary Requirements [For Renewal of Certificate of Tax Exemption]

1 Certified True Copy of the Certificate of Registration issued by the CDA under the new Cooperative
Code;
2 Certified True Copy of the Latest Articles of Cooperation and the Latest By-Laws of the Cooperative;

3 Certified True Copy of the current Certificate of Good Standing from CDA, effective on the date of
application; and
4 Certified True Copy of Latest Financial Statements of the immediately preceding year duly audited by a
BIR accredited independent certified public accountant.
BIR FORM NO. 1945
Guidelines and Instructions

This form shall be duly accomplished in (3) three copies which must be signed by the applicant who may either
be the President or any responsible officer of the cooperative authorized to file this application for and in behalf of
the cooperative. All fields must be mandatorily filled-up, if not applicable the words "NOT APPLICABLE" OR
"NONE" should be an appropriate response.

This form shall be submitted only to Revenue District Office of the Bureau of Internal Revenue where the
cooperative is registered together with all the necesary documents mentioned in Part IV of this form.