Republic of the Philippines

Department of Finance
BUREAU OF INTERNAL REVENUE
REGION NO. 7
Quezon City

APPLICATION FOR TAX CLEARANCE

(Individual)

I, _________________________________ with Tax Identification Number (TIN) ______________

Filipino, Of Legal age, married/single, permanently residing at ___________________________________
_______________________ presently connected with ________________as ______________________
_____________ after having been duly sworn to in accordance with law hereby depose and state:

1. That __________________________________with T.I.N. _____________________ is a

corporation/company duly recognized and existing under and by virtue of the Laws of the Philippines with
Office located at _______________________________________________

2. That _______________________ is registered with BIR under Certificate of Registration No.

_____________________ issued at __________________________________________

3. That for the last ____________ year, it has been engaged in the Business
as___________________________________ and has consistently and faithfully paid all taxes, fees and
imports due from it;

4. That this affidavit is being submitted in order to secure a Tax Clearance Certificate for
entering into any contract with the Government/Private Agency requiring the same under Executive
Order No. 398 as implemented by RR NO. 3-2005.

5. PURPOSE: ______________________________________________________________

ATTACHED THE FOLLOWING REQUIREMENTS:

a) Documentary Stamp (2 pieces, do not affix) (P15.00 each) P30.00

b) Certification Fee (P100.00)
c) Request Letter
d) Authorization of Representatives
e) Annual Registration Fee 2009
f) Verification Slip-from Revenue District Office
g) Income Tax Returns for two (2) years (Xerox copy only)

______________________________
Signature of Application/Affiant

SUBSCRIBED AND SWORN to before me this ________ day of ________ 201_ in

______________________________ applicant exhibit to me his/her Community Tax Certificate
No.___________________ issued at ___________________on ________________________.

Doc. No. ________

Page No. ________
Book No, ________ ___________________
Series No. of _______ Notary Public

Affix
P15.00
Documentary Stamps Tax