Name of Enterprise / Certificate of Registration No.

: _________________________________________________________
Zone Location: _______________________________________________________________________________________

Inventory List of Assets/Goods for Disposition/Local Sale

Assets/Goods Acquired MORE THAN Five (5) Years of Acquisition

Particulars on Importation / Local Purchases Remarks

Condition of
PEZA Permit Issued* Invoice of Supplier / Source* PEZA Incentives Availed?
Assets/Goods
Description of Machines/ Equipment Qty. Name of Supplier / Address of Supplier /
Imported “Tax and Duty-exempt”; Locally purchased Obsolete /
Type of Permit
PEZA Permit Source of Equipment Source of Equipment Cost/Value* “VAT-paid” or Locally purchased “VAT-Zero-rated”;
Issued (8101, 8105, PEZA Permit No. Date No. Working or
8112, others) Date (USD/PhP) Pls. also indicate reference nos. of permits issued by
other gov’t agencies, e.g. SBMA or CDC permits, etc. Defective

Total Qty. Total Cost

* Please indicate value as indicated in supporting invoice.

We certify: (a) that the above-listed machines/ equipment are equipment being used for ___(name of company)_____’s _____(specify project)_____________ ; (b) to the completeness and accuracy of the above information; (c) that _____(name of company)______
acquired above listed machinery/equipment specifically for the above-subject project; and, (d) the said machines/equipment have been: (Please check appropriate box)
[ ] Consigned by _(name& address of consignor)__ [ ] Purchased [ ] Leased from _(name & address of lessor)__

___________________________________________ ___________________________________________
Signature/Date Signature/Date

___________________________________________ ___________________________________________
Name & Designation of Authorized Enterprise Official Name & Designation of Authorized Enterprise Official

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