Professional Documents
Culture Documents
TARLAC CITY
8A Zip Code 0000
9 Residence Address (Indicate complete address)
TARLAC CITY
9A Zip Code 0000
10 Contact Number 11 Email Address
000 a@gmail.com
Donee's Name (Attach additional sheet/s, if necessary)
12 (Last Name, First Name, Middle Name for Individual OR Registered Name for Non-Individual)
Donee's Tax Identification Number
A
B
C
D
E
Are you availing of tax relief under a Special
13 Law/International Tax Treaty? Yes No 13A If yes, specify
Signature over Printed Name of Taxpayer/Authorized Representative/Tax Agent Signature over Printed Name of President/Vice President/
(Indicate Title/Designation and TIN) Authorized Officer or Representative/Tax Agent (Indicate Title/Designation and TIN)
Tax Agent Accreditation No./ Date of Issue Date of Expiry
Attorney's Roll No. (If applicable) (MM/DD/YYYY) (MM/DD/YYYY)
PART III - DETAILS OF PAYMENT
Particulars Drawee Bank/Agency Number Date (MM/DD/YYYY) Amount