Annex A

Report on Personal/Substituted Service

I hereby declare that I served the document(s) listed herein to the following taxpayer(s)/person(s):

Mode of Service
Document Name of Person Served Where Documents Were Served/Delivered
(Check Appropriate Box)
(2) (3) (4)
(5)
Check the Appropriate Box
Corresponding to the Address Where the Substituted Service
Documents Were Served/Delivered) (5.2)
Date of Service Name of Person
Position/ (4.2)
(1) Assessment Served (Other
Date Name of Relationship Personal Competent
Name Notice No., than the taxpayer Address
Issued Taxpayer to the Service Clerk/ Member of
(2.1) if applicable Named in the (4.1)
(2.3) (3.1) taxpayer Registered Business Residence (5.1) Person in the Barangay
(2.2) Document)
(3.3) Address Address Address Charge of Household/ Official
(3.2)
(4.2.1) (4.2.2) (4.2.3) the Office Person of (5.2.3)
(5.2.1) Legal Age
(5.2.2)

I attest to the accuracy of the information contained herein.

___________________________________
(Signature Over Printed Name of Person
Who Served the Notices/Documents)

BIR ID No. _________________

Date Prepared: ___________________

SUBSCRIBED and sworn to before me this _ day of , affiant exhibiting to me the above-stated identification card.
 Annex A

(Person Administering Oath)