ETHIOPIAN REVENUES AND CUSTOMS

SCHED D-DIVIDENDS
AUTHORITY

Section 1 - Taxpayer Information

Taxpayer's Name: TIN: Tax Period:

Mirka Motors Manufacturing And Trading Plc 0075911146 Sep, 2022

Registration Addresse: Tax Account Number: (Official Use Only)

House No.: NEW 21422931429

Kebele: WOREDA 10 Po.Box: Tax Centre:
Woreda: NO WOREDA-148 Document Number: 1725924410010
Zone/Sub-City: GULLELE MOR- NORTH
Document Date: 05/07/2023
Region: ADDIS ABABA Ethiopia WEST SMALL TAX
Telephone Number: Fax Number:
PAYERS OFFICE
(STO) Submission Number: 23821891429
+251910241097 Submission Date: 05/07/2023

Section 2 - Electronic Tax Declaration

Total Number of Withholdees for this Tax Period 10 1.00

Total Taxable Income for this Tax Period 20 40,736.80

Total Tax Withheld for this Tax Period 30 4,073.68

Section 3 - Taxpayer Certification

I declare that the above declaration and all information provided here-with is correct and complete. I understand that any misrepresentation
is punishable as per the Tax Law and the Penal Code. Declaration of preparer (other than the taxpayer) is based on all information of
which the preparer has any knowledge.
Printed Taxpayer Name or Authorized Date Company Seal For Official Use Only
Representative

Date of Payment Receipt Number

Signature of Taxpayer or Authorized
Representative

Amount of Payment Check Number

Printed Name of Preparer Date

Cashier's Signature
Signature of Preparer

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