Republic of the Philippines September 2023 Version

Department of Finance
BUREAU OF INTERNAL REVENUE
Quezon City
ANNEX “J.5”
AMENDED
QF-TCC-06-04-2023.01

SWORN APPLICATION FOR TAX CLEARANCE

(To be accomplished by the Individual Taxpayer [Sole Proprietor, Professional, Local Employee &
Self-Employed] Securing Tax Clearance for General Purposes)

I, DENNY ROSE BATOY BONGNGAT, Filipino, of legal age, single, permanently residing at
MARAT, POBLACION, PARACELIS, MT. PROVINCE with Taxpayer Identification Number (TIN) 606-
374-238-00000, after having been duly sworn in accordance with law hereby depose and state:

1. That I am the Owner/Proprietor/Proprietress of ZC INKPRINTS PRINTING SERVICES

with business address at BALINAG ST., PUROK 5, BULANAO, TABUK CITY, KALINGA,
with Telephone/Cellular Phone No. 0945 729 1572 and email address 08drbongngat@gmail.com;

2. That my business trade name has been duly registered with the Department of Trade and Industry on
January 29, 2024 under DTI Registration Certificate No. 5720507;

3. That I registered my business with BIR under Certificate of Registration No. ______________issued at
Revenue District Office/LTDO No. 011 on January 26, 2024;

4. That, the following documentary requirements in relation to the aforesaid application are all authentic
and hereto attached in compliance with the existing policies.

_____ a. One (1) original copy of DELINQUENCY VERIFICATION REPORT (DVR);

_____ b. One (1) piece of loose documentary stamp tax worth P30.00;
_____ c. Confirmation Receipt of Electronic payment of certification fee worth Php 100.00 or other
proof of payment;
_____ d. One (1) original copy of valid and properly accomplished Special Power of Attorney (SPA) signed by
the applicant, applicable only to applications through an authorized representative; and
_____ e. One (1) photocopy of each valid identification cards (any government issued ID) with three
(3) specimen signatures of the applicant and the authorized representative.

5. That this affidavit is being submitted in order to secure a Tax Clearance Certificate for General Purposes
specifically for ______________________________.

____________________________________________
Signature over Printed Name of Taxpayer-Applicant

SUBSCRIBED AND SWORN to before me this _____ day of ______________________, 20___

in _______________________________. Affiant exhibited to me his/her valid Government Issued Identification
Card ___________________________with ID No. _________________.

Doc. No. __________

Page No. __________
BookNo._________
Series of __________ _____________________________________
Notary Public
-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.
! Affix !
! P30.00 !
! Documentary Stamp Tax !
!-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-!

Data Privacy Notice: Herein information is intended for Authorized Personnel only. Unauthorized disclosure is punishable by laws, as
mandated by R.A. 10173, also known as the Data Privacy Act of 2012, and Section 270 of the National Internal Revenue Code (NIRC)
in handling/processing of BIR data/information.