Federal Democratic Republic of Ethiopia

Ministry of Revenue
Schedule A
Federal Inland Revenue Authority Employment Income Tax Declaration
Section 1 - Taxpayer Information

1. Taxpayer’s Name (Company Name or Your Name, Father’s Name, Grandfathers Name) 3. Taxpayer Identification Number 4. Tax Account Number 8. Tax Period:
Page 1 of
Month Year __
2a. Region 2b. Zone/K-Ketema 5. Tax Center Document Number (Official Use Only)

2c. Woreda 2d. Kebele/Farmers Association 2e. House Number 6. Telephone Number 7. Fax Number

Section 2 – Calculation of Payments to Employees

Additional Benefits
j) Taxable
a) c) Employee Name d) Start Date f) Total
e) Basic g) Taxable i) Other Income l) Cost m) Net n) Employee
Seq b) Employee TIN (Name, Father’s Name and Grandfather’s of Transportation h) Over k) Tax Withheld
Salary Transportatio Taxable (Sum Columns Sharing Pay Signature
Num Name) Employment Allowance Time
n Allowance Benefits e, g, h, and i)

Transfer Totals from All Continuation Sheets to this Line >>

Total
(line 20) (line 30)
Section 3 – Calculation of Tax Due this Period Section 4 – Employees Removed from Payroll as of this month For Official Use
Only
Number of Employees on Your Payroll for this Tax Period Seq Employee’s Name
10 Employee TIN Date of Payment
Num (Name, Father’s Name, Grandfather’s Name)
Total Taxable Income
20 Receipt Number
(From Column j Above)
Total Tax Withheld
30 Amount of Payment
(From Column k Above)

Cheque Number

Cashier’s Signature
Section 5 – Taxpayer Certification

I declare that the above declaration and all information provide here-with (including continuation sheets) is correct and complete. I Taxpayer Signature & Date Employer Seal Preparers Printed Name, Signature & Date
understand that any misrepresentation is punishable as per the tax Laws and the Penal code. Declaration of preparer (other than the
taxpayer) is based on all information of which the preparer has any knowledge.

Ministry of Revenue (Draft as of 2/24/2006) FIRA Form 1103 (5/2006)