AFFIDAVIT – DECLARATION
OF CURRENT YEAR’S GROSS INCOME
Republic of the Philippines ) Agent’s Code:
Province of _____________________ ) COMPANY AFFILIATION : ( ) PAL ( ) PPI
City/ Municipality of ______________ ) ( Pls. put “X” mark )
CROSS SELLER : ( ) YES ( ) NO
I __ ________, also known as _________________________, of legal age,
single/married, residing at _______________________________________, after being sworn in
accordance with law, depose and say that::
1. I receive professional/talent/service fees as _______________: (Please check appropriate box/es)
Practice of profession or calling Management & technical consultants
Professional entertainer Bookkeeping agents and agencies
Professional athlete Other recipient of talent fees
Director Director, who is not an employee of the company
Insurance agents and adjusters Juridical person in the practice of profession
Others: Specify __________ _____
2. As such, I have received a gross income of P _ __ for the current year as of
3. I am executing this Affidavit – Declaration as a requirement of Revenue Regulations No.
__30-2003 of the Bureau of Internal Revenue in the determination of the applicable
creditable withholding tax rate (10% or 15%) to be imposed by withholding agent/s.
IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of ______ in the
Municipality of ___________, Province of _______________, Philippines.
Affiant – Declarant
SUBSCRIBED and sworn to before me, in the City/ Municipality of _____________, this
______ day of __________ affiant exhibiting to me his Community Tax Certificate No.
______________ issued at __________________ on ___________.
My commission expires on _____________
Doc. No. : _________
Page No. : _________
Book No. : _________
Series of 20 _______