Here is the form to be submitted by Payor or Withholding Agent to the BIR for the individual payee with no withholding tax or 5% withholding tax for income less than Php 3M.
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Annex “C”
INCOME PAYOR/WITHHOLDING AGENT’S SWORN DECLARATION
I, _________________________________________________,
____________________________, of legal age, single/
(Name of Proprietor/Authorized
Officer)
(Citizenship)
married, the designated _______________________________________
of _________________________________
(Designation/Position) (Name of Withholding Agent)
with Taxpayer Identification Number (TIN) __________________________________, after having been duly sworn in
accordance with law hereby depose and state:
1.
That there are ____________
income payees (self-employed individuals) where no withholding is made,
consisting of the following:
|
Type of withholding
NOT withheld
|
Number of income payees
|
|
Expanded WT only
|
|
|
WT on VAT/Percentage Tax only
|
|
|
Both expanded and VAT/Percentage tax
|
|
|
Total
|
|
2.
That the above
payees where no withholding tax is deducted from their income payment/s have
executed the required Income Payee’s Sworn Declarations on the amount of gross
receipts which they expect to receive for the year ______________,and these
sworn declarations are duly received together with copies of their Certificate
of Registration (COR);
3.
That there are
_________individual income payees withheld five percent (5%) withholding tax
rate due to their submission of “Payee’s
Sworn Declaration of Gross Receipts/Sales” stating that their gross
receipts/sales shall not exceed ₱3,000,000 (₱3M) for the current year, while
______non-individual payees submitted “Income Payee’s Sworn Declaration stating
that their gross receipts/sales shall not exceed P720,000 for the current year;
4.
That I am
attaching with this sworn declaration the list of individual payees subject of
items 1 and 2 above consisting of ________ number of pagers, the list of
individual payees subject of item 3 above with ____________ number of pages,
and the list of non-individual payees subject also of item 3 above with
_________ number of pages;
5.
That the
submission is in compliance with the requirements prescribed under Section _________
of Revenue Regulations No. ___________.
6.
That this
declaration, including the attached list/s, is made in good faith, to the best
of my knowledge and belief, to be true and correct, under the penalties of
perjury.
IN
WITNESS WHEREOF, I
have hereunto set my hand this ___ day of ____________, 20___ at ___________,
Philippines
__________________________________________________
Signature over Printed Name of Withholding Agent/Authorized Officer of
the Withholding Agent
__________________________________________________
Designation/Position if
Authorized Officer
__________________________________________________
Name of Withholding Agent/Lone Payor
SUBSCRIBED AND SWORN to before me this
_____ day of ____________, 20___ in _______________________________. Applicant
exhibited to me his/her___________________________issued at _______________________
on _________________________.
(Government Issued ID and No.)
NOTARY PUBLIC
Doc. No.: __________
Page No.: __________
Book No.: __________
Series of ___________
(To be filled-out by the concerned Revenue Officer)
Date Received: __________________ Received by:
(MM-DD-YYYY-00001)
__________________________________________________________
Signature over Printed Name of Revenue Officer
__________________________________________________________
Designation/Position of Revenue Officer
__________________________________________________________
RDO No.
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