(To be filled up by the BIR) DLN:

PSIC:

Republika ng Pilipinas Kagawaran ng Pananalapi

Kawanihan ng Rentas Internas

Monthly Percentage Tax Return

3 For the month 4 Amended Return 5

BIR Form No.

2551M
September 2005 (ENCS)
Number of sheets attached

Fill in all applicable spaces. Mark all appropriate boxes with an X.

1 2 For the Year ended (MM/YYYY) Calendar Fiscal

12

2012

(MM/YYYY)
Background

01

2012

Yes

No

Part I 6 9 TIN

Information

Occupation Taxpayer's Name (For Individual)Last Name, First Name, Middle Name/(For Non-individual) Registered Name

000

7 RDO Code

008

8 Line of Business/ 10 Telephone Number

11 Registered Address

12

Zip Code

2600
13 Are you availing of tax relief under Special Law or International Tax Treaty? Yes Part II Taxable Transaction/ Industry Classification 14A 15A 16A 17A 18A 19 Total Tax Due 20 Less: Tax Credits/Payments 20A 20B 21 Creditable Percentage Tax Withheld Per BIR Form No. 2307 (See Schedule 1) Tax Paid in Return Previously Filed, if this is an Amended Return 14B 15B 16B 17B 18B ATC No If yes, specify Taxable Amount Tax Rate Tax Due

Computation of Tax

14C 15C 16C 17C 18C

14D 15D 16D 17D 18D

3%

14E 15E 16E 17E 18E 19

0.00

20A 20B 21 22

Total Tax Credits/Payments (Sum of Items 20A & 20B)

22 Tax Payable (Overpayment) (Item 19 less Item 21) 23 Add: Penalties Surcharge 23A 23B

Interest 23C

Compromise 23D

0.00 0.00

24 Total Amount Payable/(Overpayment) (Sum of Items 22 and 23D)

24

If overpayment, mark one box only: To be Refunded To be issued a Tax Credit Certificate I declare, under the penalties of perjury, that this return has been made in good faith, verified by me, and to the best of my knowledge, and belief, is true and correct, pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof. 25

0
President/Vice President/Principal Officer/Accredited Tax Agent/ Authorized Representative/Taxpayer (Signature Over Printed Name) PROP. Title/Position of Signatory TIN of Signatory Date of Issuance Date of Expiry

26
Treasurer/Assistant Treasurer (Signature Over Printed Name)

Title/Position of Signatory TIN of Signatory

Tax Agent Acc. No./Atty's Roll No.(if applicable)

Part III Drawee Bank/ Particulars

27 Cash/Bank 27A

Details of Payment Date Number

27B 28B 29A 30B 27C 28C 29B 30C

Stamp of YYYY
27D 28D 29C 30D

Agency

MM

DD

Amount

Debit Memo 28 Check 28A 29 Tax Debit Memo 30 Others 30A

0.00

Receiving Office/AAB and Date of Receipt (RO's Signature/ Bank Teller's Initial)

Machine Validation/Revenue Official Receipt Details (If not filed with an Authorized Agent Bank)

2551M
September 2005 (ENCS)

2600

Tax Due

0.00

0.00 0.00

Treasurer/Assistant Treasurer (Signature Over Printed Name)

Title/Position of Signatory TIN of Signatory

Stamp of Receiving Office/AAB and Date of Receipt (RO's Signature/ Bank Teller's Initial)