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Date___________, 20___ NAME OF TAXPAYER: ADDRESS: TAX IDENTIFICATION NUMBER: CLASS OF PROFESION/CALLING: CERTIFICATION This is to certify that in accordance with the REVENUE REGULATIONS NO. 30-2003, I am receiving an Annual gross professional income of less than the amount of SEVEN HUNDRED TWENTY THOUSAND PESOS (P 720,000.00) and that, I am executing this Declaration for purposes of determining the rate of withholding tax to be deducted against my professional income. ______________________ Signature ACKNOWLEDGMENT REPUBLIC OF THE PHILIPPINES ) City/Municipality of______________ ) S.S. BEFORE ME, a Notary Public, in and for the above jurisdiction, this _____,Day of _____________, personally came and appeared with _____________________ issued on ____________ at ____________ known to me and to me known to be the same person who executed the foregoing instrument which he/she acknowledge before me as his/her free voluntary act on deed. WITNESS MY HAND AND NOTARIAL SEAL on the date and at the place first above written. Doc. No. _____; Page No. _____; Book No. _____; Series of _____ .