‘ANNEX “A1” INCOME PAYEE’S SWORN DECLARATION OF GROSS RECEIPTS/SALES (For Self-Employed and/or Engaged in the Practice of Profession with Lone Income Payor) 1_INeY GitKoe G+ FORE Sek Evento __.of legal age, single! married to a oo _____ permanently residing at ucts “SARE OMA Somoee _ ___with ‘Taxpayer Identification Number (TIN) ______ after having been duly sworn in accordance with law hereby depose and state: 1, That derived my income only from DENK PENRO SDR«eoN Tape) ‘Bal LP with Taxpayer Identification Number and business address at Q- FUE. CT-/ BURA OW: wry 2. That forthe curent year £012) _, my gross receipts will not exceed Two Hundred Fifty Thousand Pesos (P250,000.00) and that 1 am registered as a non-VAT taxpayer, that whatever is the amount of income received, 1 will comply with the requirement to file my Income Tax Retum on the prescribed due date. For this purpose, I opt to aval of either one of the following: Graduated Income Tax Rates under Section 24(A)(2}(a) ofthe Tax Code, as amended, based on the taxable income, With this selection, I acknowledge that I am subject to 0% income tax, thus, not subject 10 creditable withholding tax; subject to percentage tax, if applicable, and will ile the required percentage tax returns or subject to withholding percentage tax, in case of government money payments. GB Eight Percent (8%) income tax rate under Section 24(A)(2)\b) of the Tax Code, as amended, based on ‘708s receipts/sales and other non-operating income - with ths selection, I understand that this is in lieu of ‘the graduated income tax rates and the Percentage Tax under Section 116 of the Tax Code, as amended; thus, no withholding tax shall be made; 3. That based on my selection above, if my gross sales/recipts and other non-operating income exceeds 250,000.00 but not ‘over P3,000,000.00, my afore-stated lone income payo shall automatically withhold the prescribed rate of withholding tax: a In case of Graduated Income Tax Rates, I acknowledge that aside from income tax, Iam subject to business tax (Percentage Tax, if applicable) and creditable withholding of income in excess of 250,000.00, and business tax withholding, if any, are applicable onthe entire income payment; OR ». In case of Eight Percent (894) income tax rate, I acknowledge that I am only subject to income tax and thus, to the ereditable withholding income tax in excess of P250,01K) 00; 4, That [duly execute this SWORN DECLARATION in compliance with the requirement prescribed under Section _ of Revenue Regulations No. 5 That I declare, under the penal of perjury, that this deslaration has been made in good faith, and to the best of my Jinowledge and belie tobe true and comet JAN 2.3 om10 IN WITNESS WHEREOF, | have hereunto set my hand this“ ‘day of 20, Philippines SUBSCRIBED AND SWORN (o before me this Applicant — exhibited me hisfher Roll No. 67688 LE Compliance/New Member PTR No. 8545698/Jan. 3, 2019 IBP No. 063687/Jan. 5, 2019 Embarcadero, Juban, Sorsogon * Tout hy the withholding agendome payor) ~ ceived by: m ms RECEI Vv “Signore one Printed Nome of the Willing Agent Paver or Authorid Ofer 20 FEB aT DENK TEMRO soncocerlice @ Sepia na tne Application for ll 901 Rawarthan ng Rentas Internas ‘ a Registration Janary 2600 (ENCS) ‘or Sel joyed and Mixed Income 78] 1926 P| ose Tesccter sete CAR eae eee Th ale wile spaces Wark al appropriate boxes wih an art SEE “Taxpayer nfomnaton Frvannaver tips [Tonge Pometoane Tene fe Renter oa > CProfessional Citaust > C1 Branch Office oe) >| 4 Tamayer Wenthemon No ROO Cove ie Sex We Fecuetunenaret® O.O]frestimeissrany > =O te 7 Te [Citizenship ‘Date of rv Organization Date >| FLoREcet 7 Sk, ARDS BNSC, Wory was pL hues ltt [o,¢/1,9,4,0 Fir Ranres ies Pie ace corp ea) ip Code [1 Telophone Naber | Bvers waKELONA Cl State "Bs > Employment statis of Spas ‘SingleNWidowWidowerLegally Separated (No dependents) (Head of the Family ‘Locally Shi with nes dependent (C) Lecaty sear nied dependent Employed Aad [El vaoncower uth untied cvenion —(C} Bowron iter (No. 7432) (Engaged in BchessPracte Caries Preteen 26. ajo" aaional Exemptone! Premium Deductons ft hesband nd we hose agronomy. pcre doesn exceed 25,0000 pet ae. > Lo] Huston cis acne xometin and ary prem coductone Wie care sonal xerpon sn ary promi cadesore Uhh Wer othe aban 27 spouse vomation : : oe : Pet Spas Taxpayer Wonton urbe _spnse Nae - 0.0.0) at Gana FraNene Wie Name Spouse Tamar Sie" Eroloyers Name ne 70 e = non hier . Se +) Physically 35 3 % * - - = a 20c 00 30 lis a : a A x8 | xe so | aE - * = = 2x 28 sf 32 aE = = = on Rare FT i Tar Lastname Petane ta ame "baw stein ‘vaca i Bo ay aE * 3 © . * 33F_¥ Reston Parent Tiere CT Site ‘Queiied Serar Gilzon ra im ar Your > a ‘Sceesive epyents (ith revs erployer) win he clear year) or atresia # pect Concur anpiyrert (th oor more enseyers atthe sare te wit he cata yea) aT TOn éeciare. under the penalties of oeriur. that this form has been made in good faith, vefied by me and to the best of my knowledae and vt wos ar sock utube vonsons otha Nia Maal Severe Cage as smonde, ane he euoons sed dara etek “aipayer oon NT fi? _RbO oose > [retest = a = ~ Enpioyers Buenos — — pastors Gade FAT Monon Code @ Eecity Dale Dao Cotcnion ‘s etnies | {Canaan Esanpien niericnsanpied) | (Oise onion ce cr 7 io * Or atocbucs leave Nar m4 declare, under paraiso pany hati frm has baen mad in good fh vie by a Reon tro andes bol fry ores and eae cw and cect, pursuant toe powers he e Naver lomet Rovonve Code 2 arene, and the requatonelmued uncer aubnty teres. a) Fete es w by SIR) TEPLOVER AUTHORIZED AGENT Te Foiion of Salo Care oe Nore) Seer ‘A For Gxt amoloyed! Profesional Nowe ncore neil. "tte Get ran aoeonet nonngrame sees 2Mayes Fei ppeabl, $M cent oRagatton of snes Name Sa dtc opicon ote sted prone nance of tote sama pornos Gatco Ragen Sacto epson 8 For Tost st aan CcForeuta~ Dea Cutie oth acne nore 1 Update rade rama upon recip of DTI Cerca of Repsbation of Businss Name, 2 Taye shoul ato the eed trays bing before te release of te GF Cerio of Rog POSSESSION OF MORE THAN ONE TAXPAYER IDENTIFICATION NUMBERITIN) IS CRIMINALLY PUNISHABLE PURSUANT TO THE ‘PROVISIONS OF THE NATIONAL INTERNAL REVENUE CODE OF 1997, AS AMENDED.(Tobe a vt) DUN: BIR Form No. pi icecrec tree Payment Form 0605 ‘Kawaninan ng Rentas Internas uly 1980 (ENS) [Firat pen spacs, Marco pponrte oxs wih an CO 7] Hh """" ne fo FECREMCE | oka ee Tae ae] sa.atsrul loetl ..|eLoee| +L] wl] [efor comuce Accu ee ee | ctr, under the ponaies of perun that his document has been ‘made n good ath, vera by me, and othe best of my kxgutedge and bolts rue ana corect, pursuant to the provisions ofthe National Inte Reverue Code, as anendad, adhe egustins ised under [BIR Form 0605 (ENCS) - PAGE 2| REVENUE OFFICIAL RECEIPT RORNO RORMID 1807 OSI DATE: €2200019 SS AM [BUGTONG BARCELONA SORSOCON-712 iene MODE OF ParnaENT ean axonea fr OME |