AFFIDAVIT OF NON-SUBMISSION OF

CERTIFICATE OF INCOME TAX WITHHELD

I, _________________________________, hereby certify that I did not furnish my current

employer, CBE Companies PH, Inc., a copy of 2020 Certificate of Income Tax Withheld on
Compensation (BIR Form 2316) from my previous employer ____________________________.

Therefore, CBE Companies PH, Inc. has no basis of combining any personal income from my
previous employer for the taxable year 2020.

In view of omission to submit the required BIR Form 2316, I hereby undertake that I shall be
responsible in computing and paying the appropriate tax to the Bureau of Internal Revenue from
my income from all sources on or before April 15, 2021.

I hereby hold free and harmless and indemnify CBE Companies PH, Inc. its parents, its affiliates
and its successors-in-interest, stockholders, officers, directors, agents or employees, for any
obligations, costs, and other expenses in relation to the non-withholding of the appropriate tax in
relation to my combined income.

__________________________
Signature over Printed Name
Taxpayer

ACKNOWLEDGMENT

Republic of the Philippines)

) S.S.

BEFORE ME, a Notary Public in and for _______________, personally appeared to me

on ________________ , with Government ID and No. _______________ known to me and to me
known to be the same persons who executed the foregoing instrument and who acknowledged to
me that the same is their free and voluntary act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this ___ day of
_______________ at ______________.

Doc. No. ____;

Page No. ____;
Book No. ____
Series of 2021.