ANNEX“

A-1”

I
NCOMEPAYEE’
SSWORNDECLARATI
ONOFGROSSRECEI
PTS/
SALES
(
ForSel
f-
Empl
oyedand/
orEngagedi
nthePr
act
iceofPr
ofessi
onwi
thLoneI
ncomePay
or)

I
,__
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,ofl
egal
age,
singl
e/mar
ri
edt
o
(
Name) (
Cit
izenshi
p)
_
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_per
manent
lyr
esi
dingat_
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__
(
NameofSpouse)
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__wi
th
(
Addr
ess)
Tax
pay
erI
dent
if
icat
ionNumber(
TIN)_
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,af
terhav
ingbeendul
yswor
ninaccor
dancewi
thl
aw

her
ebydeposeandst
ate:

1. ThatIder
ivedmy_
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___i
ncomeonl
yfr
om _
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__
(
busi
ness/
prof
essi
onal
) (
NameofLonePay
or)
wi
thTaxpay
erI
dent
if
icat
ionNumber_
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___andbusi
nessaddr
essat_
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_

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;

2. Thatforthecur r
entyear__
_____
_ ,mygrossrecei
ptswi l
lnotexceedTwoHundr edFiftyThousandPesos(₱250,000.00)and
thatIam regi
steredasanon-VATt ax
payer;t
hatwhateverist
heamountofi ncomereceived,
Iwil
lcomplywi
thther equir
ement
tofil
emyI ncomeTaxRet ur
nont heprescr
ibedduedate.Forthi
spurpose,
Iopttoavailofeit
heroneoft
hefoll
owing:

 Graduat edIncomeTaxRat esunderSect i

on24(A)(
2)(a)oft heTaxCode,asamended,basedont het axabl
e
i
ncome.Wi ththissel
ecti
on,IacknowledgethatIam subjectto0%incomet ax,t
hus,
notsubjecttocreditabl
e
withholdingtax;subj
ecttopercentagetax,i
fappli
cable,andwi l
lfi
l
et herequi
redpercent
aget axreturnsor
subjectt owit
hholdi
ngpercent
aget ax,
incaseofgovernmentmoneypay ments.

 EightPercent(8%)i
ncomet axr ateunderSect
ion24(A)
(2)
(b)oftheTaxCode,asamended,basedongross
receipt
s/sal
esandot hernon-operati
ngincome-wi t
hthissel
ecti
on,Iunder
standt
hatthi
sisinlieuofthe
graduatedincometaxratesandt hePercent
ageTaxunderSect
ion116oftheTaxCode,
asamended; t
hus,no
withholdi
ngtaxshal
lbemade;

3. Thatbasedonmyselect
ionabove,i
fmygr osssal
es/recei
ptsandothernon-
oper
ati
ngincomeex ceeds₱250,000.00butnot
over₱3,
000,
000.
00,
myaf ore-
stat
edlonei
ncomepay orshal
lautomat
ical
lywit
hhol
dtheprescr
ibedrat
eofwithholdi
ngtax:

a.I
ncaseofGr aduatedIncomeTaxRates,Iacknowledgethatasidef
rom incometax,Iam subj
ecttobusi
ness
tax(Per
centageTax,i fappl
icabl
e)andcr edi
tabl
ewi t
hholdingofincomei nexcessofP250, 000.
00,and
busi
nesstaxwithhol
ding,i
fany,ar
eappl
icableontheenti
reincomepayment ;
OR

b.I
ncaseofEightPercent(8%)incometaxrat
e,Iacknowl
edgethatIam onl
ysubj
ectt
oincomet
axandt
hus,
to
t
hecredi
tabl
ewithholdi
ngincomet axi
nexcessofP250,
000.00;

4. ThatIdul
yexecut
ethisSWORNDECLARATI
ONi
ncompl
i
ancewi
tht
her
equi
rementpr
escr
ibedunderSect
ion_
___ofRev
enue
Regul
ati
onsNo.____
____
;

5. ThatIdecl
are,underthepenal
ti
esofper
jur
y,t
hatt
hisdecl
arat
ionhasbeenmadei
ngoodf
ait
h,andt
othebestofmy
knowl
edgeandbelieft
obetr
ueandcorr
ect
.

I
NWI
TNESSWHEREOF,
Ihav
eher
eunt
osetmyhandt
his_
__dayof_
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20_
__at_
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_,Phi
l
ippi
nes

_
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Si
gnat
ureov
erPr
int
edNameofI
ndi
vi
dualTaxpay
er

SUBSCRI
BED AND SWORN to beforemet hi
s_ _
___dayof_ _
_____
_____
,20__
_in_ __
_____
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_____
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_.Appl
i
cant
exhi
bit
edtomehis/her_
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_____
_ _
___
_issuedat___
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_____
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_on___
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_____
_____
_____
.
(
Gov
ernmentI
ssuedI
DandNo.
)

NOTARYPUBLI
C
Doc.No.
: ______
____
PageNo.: _
_____
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BookNo.: _
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Seri
esof ____
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__

Affix₱30.
00
Documentary
StampTax

(
Tobef
il
led-
outbyt
hewi
thhol
dingagent
/lonepay
or)

Dat
eRecei
ved:__
_____
_ _
____
_ _
___ Recei
vedby
:
(
MM- DD-YYYY-00001)
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Si
gnat
ureov
erPr
int
edNameoft
heWi
thhol
dingAgent
/Pay
ororAut
hor
izedOf
fi
cer

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Desi
gnat
ion/
Posi
ti
onofAut
hor
izedOf
fi
cer

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NameofWi
thhol
dingAgent
/LonePay
or