Annex “C”

SWORN DECLARATION

REPUBLIC OF THE PHILIPPINES

PROVINCE OF ______________________
CITY/MUNICIPALITY OF ______________

I, NAME OF REPRESENTATIVE, Filipino, of legal age designated as POSITION OF

REPRESENTATIVE of COMPANY NAME with business address located at ADDRESS OF
COMPANY do hereby certify the following:

 That in compliance with the requirements of Revenue Regulations No. 2-2015,

submitted herewith is 1 (one) DVD-R containing ## (NUMBER) BIR form 2316
covering the period December 31, 2022.

 That the contents of the DVD-Rs being submitted herewith conform to the
conditions/ specification requirements set by the Bureau of Internal Revenue.

 That the soft copies of the BIR Form 2316 contained in the DVD-R being submitted
herewith are the complete and exact copies of the original thereof.

I HEREBY DECLARE UNDER THE PENALTIES OF PERJURY THAT THE FOREGOING

ATTESTATIONS ARE TRUE AND CORRECT.

NAME OF REPRESENTATIVE
Name and Signature of
Authorized Representative
TIN: 000-000-000-00000
SUBSCRIBED and sworn to before me, in the City/Municipality of ______, this day of
____, 20___ by ________________ with Residence Certificate No. __________ issued at
___________, on _________ 20___.

Notary Public
Doc. No.____
Page No. ____
Book No. ____
Series of ____