ANNEX "B"

SUMMARY REPORT OF ISSUED CERTIFICATION OF TAX PAYMENTS

______________________________________________
(Name of Concerned Revenue Office)
For the month of _________________

CERTIFICATION FEE

CONTROL DATE OF DATE OF TAXPAYER COLLECTION RETURN BANK TAX REMARKS/

NAME OF TAXPAYER AMOUNT
NO. CERTIFICATION OFFICIAL RECEIPT OFFICIAL IDENTIFICATION DATE PERIOD CODE TYPE STATUS
NO.
RECEIPT NO.

Prepared by: Noted by:

(Name and Designation (Name of Head of Office)