Escolar Documentos
Profissional Documentos
Cultura Documentos
DLN:
BCS No.
Republika ng Pilipinas
Kagawaran ng Pananalapi
PSIC:
1704
May 2001
For the
2 Year Ended
( MM / YYYY )
Calendar
Fiscal
3 Amended Return?
Yes
Part I
TIN
Taxpayer's Name
7 0
Information
RDO Code
8 Line of Business/
Occupation
10 Registered Address
12 Date of Incorporation
(MM/DD/YYYY)
Part II
AT C
No
Background
11 Zip Code
12A
12B
13 Taxable Income
13
15
14A
14B
14C
14D
16
15A
15B
15C
15D
17
16A
16B
16C
16D
17A
17B
18
19
20
20
21
Less:
(See Schedule I)
21A
21B
22
23 Tax Rate
23
Add:
10%
24
Penalties
Surcharge
Interest
25A
Compromise
25B
25C
25D
26
We declare, under the penalties of perjury, that this return has been made in good faith, verified by us, and to the best of our knowledge and belief, is true
and correct, pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof.
27
28
President/Vice-President/Authorized Representative
(Signature over printed Name)
Tax Agent
Date Issued
MM
DD
YYYY
Place of Issue
29
30
Part III
31
32
D e t a i l s of P a y m e n t
Date
Number
MM
DD
YYYY
Drawee Bank/
Particulars
Agency
33 Cash/Bank
Debit Memo.
34 Check
34A
34B
34C
35 Tax Debit
35A
Memo
36A
36B
36 Others
Amount
Amount
33
34D
35B
35C
36C
36D
Machine Validation/Revenue Official Receipt Details (If not filed with the bank)
Schedule I
Stamp of Receiving
Office and
Date of Receipt