(To be filled by the BIR)

DLN PSOC PSIC

BIR Form No
Republica ng Pilipinas Annual Information Return
Kagawaran ng Pananalapi of Income Taxes Withheld on 1604-CF
Kawanihan ng Rentas Compensation and Final Withholding Taxes July 1999(ENCS)
Fill in all applicable spaces Mark all appropriate boxes with an "X".

1 For the year(YYYY) 2 0 1 2 2 Amended return? ¨ Yes ý No 3 No of Sheets attached

Part I Background Information

4 TIN 6 Line of Business/
T A X 1 2 3 4 5 5 RDO Code Manufacturing
Occupation

7. Withholding Agent's name(Last Name,First Name for Individuals)/(Registered Name for Non-Individuals ) 8 Telephone No
ABC Corporation Ltd., Philippines 123131

9 Registered Address 10 Zip Code

Address1 Address2 6 0 0 0

11 Incase of over withholding/overremittance after the year-end adjustment on compensation If yes specify
have you released the fund to your employees ¨ Yes ý No Date of Refund

12 Total amount of Overremittance of 13 Month of first Crediting 14 Category of withholding Agent

Tax withheld under compensation Overremittance ý Private ¨ Government

Part II Summary Of Remittances

Schedule-I Remittance per BIR Form No 1601 -C
DATE OF NAME OF TAXES
MONTH ADJUSTMENT PENALTIES TOTAL AMOUNT REMITTED
REMITTANCE BANK/BANK CODE/ WITHHELD
ROR NO.IF ANY
JAN 5461.73

FEB 1787.24

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

TOTAL 7248.97
 Schedule-II Remittance per BIR Form No 1601 -F

MONTH DATE OF NAME OF TAXES ADJUSTMENT PENALTIES TOTAL AMOUNT REMITTED

REMITTANCE BANK/BANK CODE/ WITHHELD
ROR NO.IF ANY

JAN 0.00

FEB 229.76

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

TOTAL 229.76

Schedule-III Remittance per BIR Form No 1602

DATE OF NAME OF TAXES
MONTH ADJUSTMENT PENALTIES TOTAL AMOUNT REMITTED
REMITTANCE BANK/BANK CODE/ WITHHELD
ROR NO.IF ANY

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

TOTAL
 Schedule-IV Remittance per BIR Form No 1603
DATE OF NAME OF TAXES
Quarter REMITTANCE BANK/BANK CODE/
ADJUSTMENT PENALTIES TOTAL AMOUNT REMITTED
WITHHELD
ROR NO.IF ANY

TOTAL

We declare, under the penalities of perjury, that this declaration has been made in good faith , verified by us ,and to the best
of our
knowledge and belief , is true and correct , pursuant to the provisions of the National Internal Revenue Code, as amended and

S. Scott
Stamp of receiving Office
15 President/vice president/ Principal Officer/Accredited Tax Agent/ 16 Treasurer/Assistant Treasurer
Date of Receipt
Authorised Representative/Taxpayer (Signature Over Printed Name)
(Signature Over Printed Name)

Title/Position of Signatory TIN of Signatory Title/Position of Signatory

Tax Agent Acc.no/Atty's Roll No.(if appli Date of issuance Date of expiry Title/Position of Signatory