ANNEX “B41” INCOME PAYEE’S SWORN DECLARATION OF GROSS RECEIPTS/SALES (For Self-Employed and/or Engaged in the Practice of Profession with Several Income Payors) of egal age, (3) single! marred to aoa Tiss permanently residing at Boner swith “Taxpayer Identification Number (TIN} after having been duly sworn in accordance with law hereby depose and state: 6. That derived my. ‘income from various income payors, and my registered business address iat =a 7. That forthe current year my 0s receipts will not exceed Three Million Pesos (P3,000,000) and shat Tam a non= VAT registred tespayer. For tis purpose, | opto avail of ether one ofthe income tax regime as follows: Graduated Income tx rte C1 Graduated Income Tax Rates under Section 24(A)(2)(a) of the Tax Code, as amended, based on the taxable income. With this selection, I acknowledge that I am subject to creditable withholding tax atthe presribed rate; subject to percentage tax and will file the required percentage tax returns or subject to withholding percentage tax, in case of government money payments Bight Percent (8%) Income tax rate C1 Eight Percent (8%) income tax rate under Section 24(A\2Xb) ofthe Tax Code, as amended, based on gross receiptsisales and other non-operating income - with this selection, Tunderstand that this sin iew of the raduated income tax rates and the Perentage Tax under Section 116 ofthe Tax Code, as amended; thus, ‘only the editable income withholding tax based on the preseribed rate shall be made; “That based on my selection above, if my gross salesrecipts and other non-operating income exceeds ¥3,000,000, my income payor Mwithholding agents shall automatically withhold the higher rate of withholding of ten percent (10%) in the case of, income items with two @) prescribed creditable withholding tax rate depending on the total amount of income payment received: «© Incase of Graduated Income Tex Rates, I acknowledge that aside from income tax, I am subject to business tax (VAT) unless expressly exempted; and consequently subject to withholding of income, Moreover, if the payors government entity, business tax withholding applies; OR 4 In cate of Bight Percent (896) income tax rate, I acknowledge that | am no longer qualified to avail ofthis option since my income exceeds 3,000,000 and thus, the praduated income tax rates above stall sutomatically apply together with the consequent ibility for business taxes; That I duly exccute this SWORN DECLARATION in compliance with the requirement prescribed under Section 2 of Revenue Regulations No_L1-2018 ; 10, ‘That declare, under the penalties of perjury tha this declaration has been made in good fit, and tothe best of my knowledge and belie to be true and correct, IN WITNESS WHEREOF, | have hereunto set my hand this__day of. 20__at____. Pilippines SUBSCRIBED AND SWORN to before me this_éay of. 20 Applicant exhibited tome histher___ issued a on Ee ‘i 0m | Samp Tax To be filed-out by the withholding agenClone payor) Received by: a a RT Ra Wg pr DOR I OS