Federal Democratic Republic of Ethiopia Excise Tax Declaration Form The National Regional Government of Oromia

Ethiopia Revenues & Custom (To Be Filled Monthly) Bureau of Revenues

Authority 

Section 1 – Taxpayer Information
1. Taxpayer’s Name (Company Name or Name, Father’s Name, Grandfather’s Name) 3. Taxpayer Identification Number 4. Tax Account Number 8. Tax Period
Month Year Page 1_ of_

2a. Region 2b. Zone/K-Ketema 5. Tax Center Document Number (Official use Only)

2c Woreda 2d Kebele/Farmers Association 2e. House Number 6. Telephone Number 7. Fax Number

Section 2 – Calculation of Tax Due

b) e) i)
d) g) h)
a)Seq Category of Product / Parent Product Monthly f) Unit Cost Tax to Pay
c) Product Details Measure Cost of Production Excise Tax
Num (See Reverse for Listing of Product Categories and Tax Production (Birr) (Column g x h)
ment (Column e x f) Rate
Rates) (units) (Birr)

Totals from Attached Continuation Sheets if used

Total Line 10 > Line 20>
Section 3 – Calculation of Tax due this Period For Official Use Only
Date of Payment Receipt Number
10 Total Cost Of Production Cheque Number Cheque Number
20 Total Excise Tax Payable (from column i above) Cashier Signature

Section 3 – Taxpayer Certification

Printed Name of Taxpayer or Authorized Officer Signature __________ Printed Name of Preparer: Signature_______
Taxpayer Seal
Date _______ Date __________

Oromia Bureau of Revenues OBR Form 2101 (5/2006)