ANNEX “C”

BIR Form No. ______

PRDM No. :
Date :
Republic of the Philippines
DEPARTMENT OF FINANCE
BUREAU OF INTERNAL REVENUE

PRODUCT REPLENISHMENT DEBIT MEMO

Large Taxpayers Service – Excise Group

2/F, Rm. 216 A & B, BIR National Office
Diliman, Quezon City

Attention : Head Revenue Executive Assistant

LTS- Excise Group
Sir/Madam:

We have authorized the debit of product replenishment on excisable articles pursuant to Revenue
Regulations No. _________ in relation to Section ___ of the National Internal Revenue Code, detailed as
follows:

Product Description/Brand Name/Model Quantity Excise Tax Due

Volume Unit of measure P

TOTAL P

COMPANY NAME :
TIN
Assessment No.
Volume/Amount of product replenishment
tax debit

Amount available as of date of utilization :

Amount of product replenishment tax debit :
Balance as of date :

REFERENCE:

PRC No. :
Date Issued :
Date revalidated :
Original Amount :
No. and date of last PRDM issued :

Purpose :

RecommendingApproval: Approved:

Division Chief Head Revenue Executive Assistant

LT- Field Operations Division Large Taxpayers Service – Excise Group
Note:
This PRDM is valid within thirty (30) calendar days from issuance hereof and subject to liquidation within forty five (45)
calendar days upon transmittal. Any erasure shall render this PRDM invalid. Furthermore, this PRDM is being issued
against the subject PRC on the basis of the remaining balance of the said PRC as evidenced by the entries, if any, posted at
the subject PRC’s dorsal portion. Final acceptance of this PRDM for product replenishment shall, however, be based on the
PRC’s actual creditable balance as verified by the accepting office.