REPUBLIC OF THE PHILIPPINES )

CITY OF __________ ) SS.

SWORN DECLARATION OF GROSS INCOME

I, [AUTHORIZED REPRESENTATIVE], of legal age, Filipino, and a resident of

[ADDRESS], after having been duly sworn to in accordance with law, do hereby depose and
say:

1. That I am the [DESIGNATION] of a business establishment named [COMPANY

NAME] with business address at [COMPANY ADDRESS].

2. That the income of the said business establishment for the year 2022 is P [AMOUNT
OF SALES] breakdown as follows:

1st Quarter XXX

2nd Quarter XXX
3rd Quarter XXX
4th Quarter XXX
TOTAL P XXX

[AUTHORIZED REPRESENTATIVE]
(Affiant)

SUBSCRIBED AND SWORN to me before this _____ day of ________2023 in the City of
____________________affiant having exhibited to me his/her Tax Identification Number
_______________ issued in _________________.

Doc.No. _______;
Page No._______;
Book No._______;
Series of 2023