ANNEX A

AFFIDAVIT DECLARATION
OF CURRENT YEARS GROSS INCOME

Republic of the Philippines )

Province of _____________________ )
City/ Municipality of ______________ )

I _________________________, also known as __________________________, of

legal age, single/married, residing at __________
_____________________________, after being sworn in accordance with law, depose
and say that::

1. I receive professional/talent/service fees as _______________: (Please

check appropriate box/es)

Practice of profession or calling Management & technical consultants

Professional entertainer
Professional athlete
Director
Insurance agents and adjusters
Others:
_______________________
Bookkeeping agents and agencies
Other recipient of talent fees
Director, who is not an employee of the
company
Juridical person in the practice of
profession
Specify

2. As such, I have received a gross income of P _____________ for the

current year as of ___________.
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 ______ day of

________ in the Municipality of ____________, Province of _________________,
Philippines.

Affiant Declarant
TIN: ____________________

SUBSCRIBED and sworn to before me, in the City/ Municipality of

_____________, this ______ day of __________ affiant exhibiting to me his
Community Tax Certificate No. ______________ issued at __________________ on
___________.
 Notary Public
My commission expires on
_____________
Doc. No. : _________
Page No. : _________
Book No. : _________
Series of 20 _______