(To be filled up by the BIR)

DLN:

PSOC:

PSIC:

Quarterly Remittance Return

of Final Income Taxes Withheld

Republika ng Pilipinas
Kagawaran ng Pananalapi

Kawanihan ng Rentas Internas

BIR Form No.

1603
November 2004 (ENCS)

On Fringe Benefits Paid to Employees Other than Rank and File

Fill in all applicable spaces. Mark all appropriate boxes with an X.
1 For the Year
(YYYY)

2 Quarter

1st

2nd

3rd

Months Reflected in this Return

Amended
Return?

4th

Yes

Part I
6 TIN

Background

10 Telephone No.

14 Are there payees availing of tax relief under Special Law or International Tax Treaty?

Government

Yes

Part II
Recipients

ATC

15 Alien & Filipino employed &

occupying the same position
as those of aliens employed
in selected multinational
companies
16 Non-resident Alien not Engaged
in Trade or Business
17 Others ( In General)*

No
If yes, specify
C O M PU TAT I O N O F TAX

Monetary Value of
Fringe Benefit

Percentage
Divisor

Tax Base
Grossed-up
Monetary Value

Tax
Rate

WF 320

85%

15%

WF 330

75%

25%

Tax Required
To Be Withheld

WF 360

18 Total

18A

18B

Less: Taxes Remitted in Return previously filed, if this is an Amended Return

19

20 Tax Still Due/ (Overremittance)

21

No

12 Zip Code

13 Category of Withholding Agent

19

Yes

RDO Code

11 Registered Address

Private

No

Any Taxes
Withheld?

Information

8 Line of Business/
Occupation
Withholding Agent's Name (Last Name, First Name, Middle Name for Individuals)/(Registered Name for Non-Individuals)

20

Add: Penalties
Surcharge

Interest

21A

21B

Compromise
21C

21D

22 Total Amount Still Due/ (Overremittance)

22
If overremittance, mark one box only:
To be Refunded
To be issued a Tax Credit Certificate
I/We declare, under the penalties of perjury, that this return has been made in good faith, verified by me/us, and to the best of my/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.
23

24
President/Vice President/Principal Officer/Accredited Tax
Agent/Authorized Representative/Taxpayer
(Signature over printed Name)
Title/Position of Signatory

Title/Position of Signatory

TIN of Accredited Tax Agent (if applicable)

Tax Agent Accreditation No. (if applicable)

Part III
Particulars
25 Cash/Bank

Debit Memo 25A

26 Check
27 Others

26A
27A

Treasurer/Asst. Treasurer
(Signature over printed Name)

Drawee Bank/
Agency

Number

Details of Payment
Date
MM DD

Amount

YYYY

25B

25C

25D

26B

26C

26D

27B

27C

27D

Stamp of Receiving
Office and
Date of Receipt

Machine Validation/Revenue Official Receipt Details (If not filed with the bank)

*Note: For tax rates and percentage of divisors, please see instruction at the back (In General)