Sworn Declaration Format

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					                                   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
                                                                 TIN: ________________

       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 ___________.

                                                                   Notary Public
                                                        My commission expires on _____________
Doc. No. : _________
Page No. : _________
Book No. : _________
Series of 20 _______

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