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Republic of the Philippines

Department of Finance
BUREAU OF INTERNAL REVENUE
Revenue District No. 89
Ormoc City
06/19/2019
Date
TAXPAYER COMPLIANCE VERIFICATION SHEET
APPLICATION FOR TAX CLEARANCE

Name of Taxpayer TIN 123-456-789-000


Trade Name Date of Registration
Line of Business Purpose of Clearance

________________________________________ __
Signature of Applicant
A. ANNUAL INCOME TAX RETURNS 1701/1702/1700- (Last 3 Years)
Year Gross Receipts Amount Paid Date Paid ROR/AAB
2019
2018
2017
B. QUARTERLY INCOME TAX RETURNS (1701Q/1702Q)
Period Covered Gross Receipts Amount Paid Date Paid ROR/AAB
1ST QRT 2019
2ND QRT 2018
3RD QRT 2018
C. MONTHLY PERCENTAGE TAX RETURNS (2551M)/VAT(2550M/2551Q)
Month Gross Receipts Amount Paid Date Paid ROR/AAB
January
February
March
April
May
June
July
August
September
October
November
December
D. MONTHLY WITHHOLDING TAX RETURNS (160E/1601C)
1601C 1601E
Amount Withhold Date Filed ROR/AAB Amount Withhold Date Paid ROR/AAB
Jan Jan
Feb Feb
Mar Mar
Apr Apr
May May
Jun Jun
Jul Jul
Aug Aug
Sep Sep
Oct Oct
Nov Nov
Dec Dec
E. ANNUAL REGISTRATION FEE (0605)
Year Amount Paid Date Paid ROR/AAB Remarks
2019 500 06/11/2019
2018
2017
COMPLIED NOT COMPLIED REMARKS SIGNATURE DATE
SUBMISSION OF SLSP
OPEN CASES
MERCHANDISE INVENTORY
1604E SUBMISSION
1604CF SUBMISSION
TCVD PENALTIES

VERIFIED AND VALIDATED: RECOMMENDING APPROVAL:

__________________________
Revenue Officer/Officer of the Day Chief, Collection Section OIC-Assistant Revenue District Officer

APPROVED:

Chief, Assessment Section Chief, Client Support Section Revenue District Officer

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