ANNEX 'A-3'

REPUBLIKA NG PILIPINAS
KAGAWARAN NG PANANALAPI
KAWANIHAN NG RENTAS INTERNAS

OFFICIAL REGISTER BOOK

BIOETHANOL-BLENDED GASOLINE (E-GASOLINE)

For the Month of __________, 200___

Manufacturer
Production Site
Address
TIN
Assessment No.

: _____________________
: _____________________
: _____________________
: _____________________
: _____________________

PRODUCTION

REMOVALS

Unleaded Gasoline
Date

ODI No.
Volume of E-Gasoline
Produced

Fuel Bioethanol
Name of Source

Date

Name and Address of

Consignee

Volume

Beg. Balance

TOTAL

I certify that all entries on this page contain true and complete details of all transactions for the period of _____________________, 2006
pursuant to existing Revenue Rules and Regulations.
PREPARED BY:

ATTESTED BY:

_________________________

_________________________

Authorized Representative

Revenue Officer on Premise

Oil Industry-Participant

TIN/ Assessment
No.

Withdrawal
Certificate
(WC)

Volume

Gains/Losses

Running
Balance