No: LAGOS STATE GOVERNMENT BOARD OF INTERNAL REVENUE THE GOOD SHEPHARD BUILDING BLOCK H. PLOT H1. CENTRAL BUSINESS DISTRICT (OPPOSITE LAGOS STATE SECRETARIAT MAIN GATE, ALAUSA ‘Website: www.lasg-ebs-rem.com e-TCC/m-TCC RENEWAL FORM INSTRUCTIONS: All information should be filled in ink and in CAPITAL letters, no abbreviation is allowed. Entries should not spill into a neighbouring block and MUST NOT exceed the total number of boxes provided. For fields with multiple choices, a value must be chosen from the available options to the right of the fields NOTE: IP THERE ARE MAJOR CHANGES IN THE DATA YOU PREVIOUSLY SUBMITTED (EXCEPT FOR INCOME AND TAX), DO NOT (COMPLETE THIS FORM BUT COMPLETE THE INDIVIDUAL (e-TCC) form or Abridged Form A (m-TCC) INSTEAD ACCOMPANIED. WITH A NOTIFICATION LETTER. TO BE FILLED BY TAX PAYER ONLY. 1 || TAXPAYER ID 2 |] uname 3 |] current TEL. No INFORMATION ON INCOME AND TAX PAID FOR THE LAST THREE YEARS... YEAR I YEAR2 YEAR3 INCOME YEARS 4 INCOME N=) TAX PAID (The above lnome and Tax figures mst agyae wih those submited on Form H2 fr e-TCC Applicant. Your "Employer must have filed form HI, otherwise processing of -TCC may be delayed) 5 || taxstation This isthe Tax Staton where you or your company is registred AUTHORISED COY 6 REPRESENTATIVE (eg Accountant) 7 |) tame, SiON, DATE FOR e-TCC/m-TCC OFFICIAL ONLY (BIR HEADQUATERS AUTHORISED SIGNATORY [J TAXPAYER ELECTRONIC TAX CLEARANCE CERTIFICATE CARD PROCESSING REQUIREMENT ~~~ CERTIFICATION [erty thatthe Tas payer refered to above has metal requirements nevesasay for processing of hisher Eletonic Tax Clearance Certificate 8 "AUTHORISED BY SIGN AND DATE 9 NOTE: Please submit your previously obtained e-TCC or m-TCC eard with 982146 pplication form. 491967TO BE COMPLETED BY TAX OFFICIALS -. REV. OFFICERTICG 10 HEAD, AUDIT & COLLECTION SECTION OST BE ON THEPAYROML OF LASS) 11 |] Rev. orricers SIGN/DATE 12 |] STAFF ID 13 |] TELEPHONE NO 14 |[ Mose Phone 7 15 ]] TAX PAYER FILE NO. 16 TAX PAYER'S COMPANY 1D. 17 ][ SENCUNANE (eo: “TAX STATION) 18 “TAK STATION LOCATION/ADDRESS 19 || TX STATIONTAGENCY CODE "ADDRESS LOCATION ne 20 PAGE (Use Lagos State Approved Street Map Only 21 || AUTHORISED BY eo. HEAD, TAX STATION 22 |] SIGNATURE AND DATE alssz146'4094ga)