ANNEX “D”

SWORN DECLARATION

I, ______________________________________, _______________ of legal age, single/

married to (Name) (Citizenship)

_______________________________________ permanently residing at ___________________

(Name of Spouse) (Address)

_______________________________________________________________ with Taxpayer

Identification Number (TIN) ______________, after having been duly sworn in accordance with
law hereby depose and state;

1. That I am employed as __________________at ___________________________

[with Salary Grade (SG) _____ - STEP ______];

2. That for the current year ____, my net taxable compensation income will not
exceed. Two Hundred Fifty Thousand Pesos (₱250,000.00)

3. That I duly execute this SWORN DECLARATION in compliance with the

requirement prescribed by the BIR;

4. That I declare, under the penalties of perjury, that this declaration has been made
in good faith, and, to the best of my knowledge and belief, is true and correct.

IN WITNESS WHEREOF, I have hereunto set my hands this _____ day of

____________, 20_____ at __________________________, Philippines.

_____________________________________
Signature over Printed Name

SUBCRIBED AND SWORN to before me this _____ day of ____________, 2022

in _____________________________, Affiant exhibited to me his/her ____________________
issued at _______________________________ on ______________________.
(Government Issued ID and No.)

NOTARY PUBLIC

Doc No.: _________

Page No.: _________
Book No.: _________
Series of _________

Affix ₱30.00
Documentary
Stamp Tax