Republic of the Philippines ANNEX “J.

5”
Department of Finance
BUREAU OF INTERNAL REVENUE
Quezon City
QF-TCC-06-04-2023.00

SWORN APPLICATION FOR TAX CLEARANCE

(To be accomplished by the Individual Taxpayer [Sole Proprietor, Professional, Local Employee &
Self-Employed] Securing Tax Clearance for General Purposes)

I, ____________________________________________, Filipino/____________(indicate nationality

for non-Filipino citizenship), of legal age, single/married to_____________________________________,
permanently residing at _____________________________________________________________ with
Taxpayer Identification Number (TIN) __________________________________, after having been duly
sworn in accordance with law hereby depose and state:

1. That I am the Owner/Proprietor/Proprietress of ____________________________________________

with business address at ______________________________________________________________,
with Telephone/Cellular Phone No. ______________________ and email address ________________;

2. That my business trade name has been duly registered with the Department of Trade and Industry on
_____________________________ under DTI Registration Certificate No. _____________________;

3. That I registered my business with BIR under Certificate of Registration No. ______________issued at
Revenue District Office/LTDO No.____________on _______________________________________;

4. That, the following documentary requirements in relation to the aforesaid application are all authentic
and hereto attached in compliance with the existing policies.

_____ a. One (1) original copy of DELINQUENCY VERIFICATION REPORT (DVR);

_____ b. One (1) piece of loose documentary stamp tax worth P30.00;
_____ c. Confirmation Receipt of Electronic payment of certification fee worth Php 100.00 or other
proof of payment; and
_____ d. One (1) original copy of valid and properly accomplished authorization letter with
photocopies of any government issued I.D. showing the picture and signature of the
applicant
and the authorized representative.

5. That this affidavit is being submitted in order to secure a Tax Clearance Certificate for General Purposes
specifically for ______________________________.

____________________________________________
Signature over Printed Name of Taxpayer-Applicant

SUBSCRIBED AND SWORN to before me this _____ day of ______________________, 20___

in _______________________________. Affiant exhibited to me his/her valid Government Issued Identification
Card ___________________________with ID No. _________________.

Doc. No. __________

Page No. __________
BookNo._________
Series of __________ _____________________________________
Notary Public
-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.
! Affix !
! P30.00 !
! Documentary Stamp Tax !
!-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-!

Data Privacy Notice: Herein information is intended for Authorized Personnel only. Unauthorized
disclosure is punishable by laws, as mandated by R.A. 10173, also known as the Data Privacy Act of 2012,
and Section 270 of the National Internal Revenue Code (NIRC) in handling/processing of BIR