LANDBANK

_________________________Branch
ETAX PAYMENT ENROLLMENT FORM
New Enrollment Updates(Please check the appropriate box for updates) Change Password Change Authorized Enrollee Additional Authorized Enrollee
Enrollment Date ______ Change Registered Name Change Account Number Additional Account Number Change email address Change Tin
REGISTERED NAME/ TAXPAYER’S NAME (Write in print) Individual NGA/SUC RDO TIN (Indicate the 12 digit number)
Corporate LGU - - -

TAXPAYER’S ADDRESS (Write in Print) CONTACT NO. E-TAXPAYER’S BRANCH CODE

(to be provided by BIR)

NAME OF AUTHORIZED ENROLLEE (Write in print) Any one(1) E-MAIL ADDRESS (Write in print, case sensitive, the number zero should USER ID (Write in print, 4 character Alpha or numeric or
Any two(2) be written as “Ø” to differentiate from the letter “O”) combination)

1. __________________________________________________ 1._______________________________________ 1. ______________________________

2. __________________________________________________ 2. _______________________________________ 2. ______________________________
3. __________________________________________________ 3. _______________________________________ 3. ______________________________
4. __________________________________________________ 4. _______________________________________ 4. ______________________________
ACCOUNT NUMBER/S TO BE ENROLLED (Please attached separate sheet for other account nos.)
SAVING ACCOUNT CURRENT ACCOUNT
1. - - 1 - -
.
2. - - 2 - -
.
DEPOSITORY’S SIGNATURE
I/we hereby agree to the terms and conditions governing the E-Tax Payment Facility to LANDBANK:

______________________________ ______________________________ ______________________________ ______________________________

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
For corporate taxpayer, a Board Resolution authorizing enrollment of the account(s) , and designating authorized enrollee/password holders shall be required. It is the responsibility of the Board of Director/ Trustees of the corporation to inform the bank of change in authorized enrollees.
FOR BRANCH USE FOR MCMD ENROLLMENT
This is to certify that all details and information written above are true, accurate and complete per validation with other required documents submitted
by the clients. Copies of documentary requirements are safekept in the branch for reference.
Verified by Enrolled by Checked by Approved by
Signature Verified by Processed by Approved by ____________________ ____________________ ____________________ ____________________

________________________ ________________________ ________________________

DATE AND TIME RECEIVED: ___________________
Distribution: Copy 1: MCMD Copy 2: Branch/EO Copy 3: Taxpayer