Monthly Remittance Return

of Creditable Income Taxes

Withheld (Expanded)

Republika ng Pilipinas
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas

For the Month (MM/YYYY)

Part I
5 TIN 139

225

Yes
Yes

315

Amended Return?

03 - March 2016

6 RDO

000

Code

040

BIR Form No.

1601-E
September 2007 (ENCS)

No. of Sheets Attached?

Any Taxes Withheld?

No

Yes

Background Information
7 Line of Business/Occupation

PRIVATE MEDICAL, DENTAL, OTHER HEALTH SER

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

9 Telephone Number

PERALTA, MA. ELEANOR ROMERO

4341774

10 Registered Address
#6 ANONAS ST. UNIT 2-3 ANONAS ARCADE PROJ. 3, QUEZON CITY

12 Category of Withholding Agent

Private
Private

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

Government
Government

Yes

No

If yes, specify -

Part II

Computation of Tax

NATURE OF INCOME PAYMENT

ATC

RENTALS (INDIVIDUAL)

WI100

14
15

ATC
TAX BASE

TAX RATE

13,352.60

5.0

14

Total Tax Required to be Withheld and Remitted

Tax Still Due/(Overremittance) (Item 14 less Item 15C)

Add: Penalties
Surcharge

17A
18

667.63
667.63

Less : Tax Credits/Payments

15A Tax Remitted in Return Previously Filed, if this is an amended return

15B Advance Payments Made (please attach proof of payment - BIR Form No. 0605)
15C Total Tax Credits/Payments (Sum of Items 15A and 15B)
16
17

TAX REQUIRED TO
BE WITHHELD

Interest
0.00

17B

Total Amount Still Due/(Overremittance) (Sum of Items 16 & 17D)

15A
15B
15C
16

667.63

17D

0.00

0.00
0.00
0.00

Compromise
0.00

17C

0.00

18

667.63