Republic of the Philippines ANNEX C

Department of Finance
BUREAU OF INTERNAL REVENUE
Quezon City

I, _____________ , Filipino, of legal with Taxpayer Identification Number (TIN) ___-___-___-000,

that I am the Owner/Proprietor/Proprietress of (COMPANY NAME) with business address at
_________________________________, with Cellular Phone No.+639______________ and
email address ___________________________; after having been duly sworn in accordance with
law hereby certify the following:

- That in compliance with the requirements of Revenue Regulations No. 2-2015, submitted
herewith is/are 1 piece of DVD-Rs containing ___ copies of scanned BIR form 2316
covering the period ________.

- That the contents of the DVD-Rs being submitted herewith conform to the
conditions/specification requirements set by the Bureau of Internal Revenue.

- That the soft copies of the BIR Form 2316 contained in the DVD-Rs being submitted
herewith are the complete and exact copies of the original thereof.

I declare under the penalties of perjury, that this declaration has been made in good faith, and to
the best of my knowledge and belief to be true and correct.

________________________________
Signature over Printed Name of Applicant

SUBSCRIBED AND SWORN to before me this __day of ______, 20__in

___________,Applicant exhibited to me his/her ______________________ issued at
_________________on_______________.

Doc. No. _________

Page No. _________ Notary Public
BookNo._________
Series of _________