Agent code: ____________

Branch: _______________

ANNEX “A”

AFFIDAVIT – DECLARATION
OF CURRENT YEAR’S GROSS INCOME

Republic of the Philippines )

Province of _____________________ )
City/ Municipality of ______________ )

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
City/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 _______