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Company Letterhead

Application Date:
Remittance Form For Tax Payment

1. Tax Payer Name : --------------------------------------

2. Tin Number : --------------------------------------

3. Tax Type : --------------------------------------

4. Payment Type : --------------------------------------

5. Tax Period : --------------------------------------

6. Income Year : --------------------------------------

7. Amount : --------------------------------------

8. Account Number : ---------------------------------------------

Authorizer Signature: Authorizer Signature:

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