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REPUBLIC OF THE PHILIPPINES )

PROVINCE OF TARLAC ) S.S.


MUNICIPALITY OF MONCADA )

AFFIDAVIT DECLARATION OF CURRENT


YEARS GROSS SALES

I, SHIELA M. PALARCA, of legal age, Filipino, single, with postal address at 09


Burgos Street, Moncada, Tarlac, after having been duly sworn to according to law hereby depose
and state that:

1. I receive professional fees as a DENTIST;

2. My Gross Income from January to March 2010 is FORTY THOUSAND


ONE HUNDRED FIFTY PESOS (Php 40,150.00);

3. I am executing this affidavit Declaration as a requirement of Revenue


Regulations No. 30-2003 of the Bureau of Internal Revenue in the
determination of the applicable creditable withholding tax rate (10% or
15%) to be imposed by withholding agent/s.

IN WITNESS WHEREOF, I have hereunto set my hand this 07 th day of April 2010, at
Moncada, Tarlac.

SHIELA M. PALARCA
Affiant
CTC No. 16603007
at Moncada, Tarlac
on ___________ , 2010

SUBSCRIBED AND SWORN to before me, in the Municipality of Moncada, Province


of Tarlac this 07th day of April 2010, by Shiela M. Palarca, personally known to me and who in
person signed before me the foregoing affidavit.