COMMUNITY TAX CERTIFICATE INDIVIDUAL CCI2012

YEAR PLACE OF ISSUE (City/Mun./Prov.) DATE ISSUED

TAXPAYER’S COPY
NAME (SURNAME) (FIRST) (MIDDLE) TIN (If any):

ADDRESS SEX

CITIZENSHIP ICR NO. PLACE OF BIRTH HEIGHT

DATE OF BIRTH WEIGHT

1 SINGLE 3 WIDOW/WIDOWER/LEGALLY SEPARATED
CIVIL
2 MARRIED 4 DIVORCED
STATUS
PROFESSION/OCCUPATION/BUSINESS TAXABLE COMMUNITY
AMOUNT TAX DUE
A. BASIC COMMUNITY TAX (₱5.00) Voluntary or Exempted (₱1.00)
B. ADDITIONAL COMMUNITY TAX (tax not to exceed ₱5,000.)
1. GROSS RECEIPTS OR EARNINGS DERIVED FROM BUSINESS DURING THE
PRECEDING YEAR (₱1.00 for every ₱1,000.00)
2. SALARIES OR GROSS RECEIPT OR EARNINGS DERIVED FROM EXERCISE OF
POFESSION OR PURSUIT OF ANY OCCUPATION (₱1.00 for every ₱1,000)
3. INCOME FROM REAL PROPERTY (₱1.00 for every ₱1,000)

Right Thumb TAXPAYER’S SIGNATURE

Print TOTAL ₱

INTEREST
 TOTAL
AMOUNT PAID ₱

(in words)

MUNICIPALITY TREASURER