Annex “A”

Republic of the Philippines

Department of Finance
BUREAU OF INTERNAL REVENUE
Quezon City

CERTIFICATE OF TAX DELINQUENCIES/TAX LIABILITIES

This is to certify that based on the record of this Bureau, (NAME OF TAXPAYER) , with Taxpayer Identification Number (TIN) 000-000-000 and
registered address at Diliman, Quezon City, has the following delinquent tax liabilities:

TAX TAXABLE PERIOD FAN/FLD/ DATE OF PARTIAL PAYMENT**

FDDA # RECEIPT OF TOTAL
TYPE FROM TO
Or FAN/FLD/FDDA BASIC PENALTIES TOTAL
* mm/dd/yyyy mm/dd/yyyy (Not applicable on
AMOUNT MANNER** and
PAN# Or TAX Per REFERENCE***
Cases pending with FAN/FLD/FDDA
Date of
CASE # DOJ/Prosecutor’s Payment/Auction
Office/Courts)
/
Garnishment
1. IT 01/01/2016 12/31/2016 123456 03/15/2018 1,000,000.0 300,000.00 1,300,000.00 1,000,000.0 ARMD
0 0 AG -12/31/2018
2. VT 01/21/2016 12/31/2016 123456 03/15/2018 500,000.00 100,000.00 600,000.00
3 DS 01/01/2014 12/31/2014 444555 03/10/2019 12,500.00 5,000.00 17,500.00 AN
.

*Tax Type Codes: IT-Income Tax; VT-Value Added Tax; DS-Documentary Stamp Tax
**Manner of Partial Payments: AIP–Approved Installment Plan; CSA- Compromise Settlement Application; APA- Abatement of Penalty Application; PAP- Proceeds of Auctioned Property/ies;
MBP- Minimum Bid Price of properties forfeited in favor of the government for lack of bidder; AG-Amount Garnished
***REFERENCE – the source of information: ARMD-Information transmitted provided by ARMD; ARMS- Information uploaded in ARMS; RCD- Information from Regional Collection
Division; AN – Information provided by taxpayer with Sworn Declaration of No Protest Filed

This Certification is issued upon the request of the taxpayer for purposes of availing the Tax Amnesty on Tax Delinquencies pursuant to Republic Act
No. 11213, as implemented by Revenue Regulations No. 4-2019. This Certificate does not include tax liabilities arising from self-assessed taxes. Tax liabilities
shown above with “AN” as reference has been validated to be unprotested as of April 24, 2019.

Issued this _______________________.

(Signature over Printed Name)

RDO / CHIEF, RCD / CHIEF, LTD/LTCED
 Annex “A”

CHIEF, LEGAL DIVISION/ CHIEF, LITIGATION DIVISION/CHIEF, PROSECUTION

RDO No. ____, __________ / REVENUE REGION NO. _____
2019-RDO Code/Office Code-000001