ANNE1 "AI"

INCOME PAYEE.’S SNVORN DECLARATION OF CROSS RECEIPTS/SALES

(For Self-Employed and/or Engaged in the Practice of Profession with Lone Income Payor)

, oFlcgnl age, single/

naarric+J to

Taxpayer Idcntificati‹»J N uilJbcr tTl N) , n!]er having bcc du]y sw\›nJ i acc‹›idance with law

hereby dcpc›sc aMd stale:

1. That I derived my

with Taxpayer ldentifical ion Number

2. That For Ihe current year , my gross rccei|›ts will not exceed Twci }4 undrcd Fifiy Tlzousan‹l Mescis (f”230.000.00) and
that I am registered os a »n -VAT tax payer; heat wlJfitevcr is hoc aT1tDu zt ‹›F i coMc rccci vecl, I wi II c‹›inpIy with the
rcquirciJacnt to file my hJcotrc Tax Return on the prescribed due date. for th is purpose, I opt tu nvail nd either ‹›nc oF the

@ Graduafcd I co*tac Tax dates u Jdcr Section 24(A)(2)(a] oF the Tax Code, as amended, bnsctl n a l!›c taxable
ii›contc. Will this selection, I acknowledge h at I am subject to 0?» income tax. thus, not subject to
creditable withl oldi»g tax; subject to ›crcci tage tax, if applicable. ailJ will file t!›c required pcrcci›tcgc tax
returns or subject to willJlJolding percentage taz, in case oFgovern zzcilt money paynJei›ts.

Eight Pcrccnt t8%) income tax rate under Section 24 tA)(2)(b) of the Tax Code, as amended, basc‹l on
gross rcccipts/sales and other non-operating income - with Ill is selection, 1 unJersl and that th is is in I ieu
of the gmduated income tax rates and the Pcrceiitagc Tax uiujcr Scctiriii 1.1 C of the Tox Code, as
amended; 11a us, no withholding tax shall be inadc;

3. Tt›at hascd of my selection above, iF my grnss sales/receipts ould oil cr noit-opcmling in comic exccoJs f°230.000.00 but not
over f’3.000,000.00, ny a Foi’c-slated lone incoilzc Mayor shall nu tonJaticall y witltl old flzc |zrcscrihed n tc ‹›f with I all ing tax:

a. In casc uf Graduated inc » The n•‹•s, I ackn‹›w)cclgc that 8s ide fit Ja i Eco 1 c tax, I and subject to
busincss tax (Purcc* laye Tax, iF Appl icablc) mcd creditable witlthnldii1g of in cnne in excess of
P230,000.00, and busi»ess tax withholding, iF a zy, arc odJpI icnble on the entire income paynJciJt; OU

b. In case of Eight Percent (8%â) income tax rate, 1 acknowleJge Illat 1 am on ly subject Io ii come I nx end
thus, to the creditable withholding inci›ine fax in excess of P250,000.00,

4. That T duly execute this S\YORN DEC£ARATION in cu»pIiancc with the requires c*1t prcscribeJ unJcr Scctictt of
ncvcnuc ftcgulations No.

5, That I declare, under l!tc pc Baltics o[ perjury, that this declaration has been laatlc in gc+ci‹l Faith, ancI tc› the best cF
nay knciwlcdge end hclicF tu be true and correct.

, 20 ai

SUBSCRI B E D AND S\VOItN to before inc this Jayofi

ON

NOTAITY PUBLIC

• Affi z P30.00 •

(No be filleh-out f9' the with Jiolñiiie ogeti til es e pay'or)

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