This document is a certificate of final tax withheld at source from income payments made during a specified period. It contains information about the income recipient and payor, including their names and tax identification numbers.
The details of income payments and tax withheld are listed. This includes payments of interest, dividends, royalties, prizes, rental income, and others. For each payment, the nature and amount of income and the tax withheld are provided.
The payor and payee or their authorized representatives declare that the information reported is true and correct according to Philippine tax regulations.
This document is a certificate of final tax withheld at source from income payments made during a specified period. It contains information about the income recipient and payor, including their names and tax identification numbers.
The details of income payments and tax withheld are listed. This includes payments of interest, dividends, royalties, prizes, rental income, and others. For each payment, the nature and amount of income and the tax withheld are provided.
The payor and payee or their authorized representatives declare that the information reported is true and correct according to Philippine tax regulations.
This document is a certificate of final tax withheld at source from income payments made during a specified period. It contains information about the income recipient and payor, including their names and tax identification numbers.
The details of income payments and tax withheld are listed. This includes payments of interest, dividends, royalties, prizes, rental income, and others. For each payment, the nature and amount of income and the tax withheld are provided.
The payor and payee or their authorized representatives declare that the information reported is true and correct according to Philippine tax regulations.
Part I Income Recipient/Payee Information Withholding Agent/Payor Information 2 TIN 3 TIN 4 Payee's Name (For Non-Individuals ) 5 Payor's Name (For Non- Individuals) 6 Payee's Name (Last Name, First Name, Middle Name) For Individuals 7 Payor's Name (Last Name, First Name, Middle Name) For Individuals 8 e!istered "ddress e!istered "ddress 8A !ip #ode #ode 1" Forei!n "ddress 1"A $i% #ode Part II #etail$ of Income Payment and %a& Withheld 'at(re of Income Payment A % ) Amo(nt of Payment %a& Withheld
*A% Withholding on P(rcha$e of +er,ice$ - &'()** (&)+* .o,ernment Withholding Agent %otal (&)+* ,e de-lare, under the %enalties o. %er/ury, that this -erti.i-ate has 0een made in !ood .aith, veri.ied 0y us, and to the 0est o. our 1no2led!e and 0elie., is true and -orre-t %ursuant to the %rovisions o. the National Internal evenue #ode, as amended, and the re!ulations issued under authority thereo.) 11 A/I)0 *1 2A'.AR3' Payor/Payor's "uthori3ed e%resentative Date 4i!ned 4i!nature 5ver Printed Name #5NF5M67 444 Date 4i!ned Payee/Payee's "uthori3ed e%resentative 4i!nature 5ver Printed Name %o 5e accompli$hed for *al(e-Added %a&/Percentage %a& Withholding 6$(5$tit(ted filing7 I de-lare, under the %enalties o. %er/ury, that the in.ormation I de-lare under the %enalties o. %er/ury that I am 8uali.ied under su0stituted .ilin! o. Per-enta!e herein stated are re%orted under 9I Form No) :'** 2hi-h Ta;/<alue "dded Ta; eturns (9I Form +&&:M/+&&*M/=), sin-e I have only one %ayor .rom have 0een .iled 2ith the 9ureau o. Internal evenue) 2hom I earn my in-ome> that, in a--ordan-e 2ith :?-+**@, I have availed o. the 5%tional e!istration under the @A Final Per-enta!e Ta; ,thholdin!/:*A Final <"T ,ithholdin! in lieu o. the @A Per-enta!e Ta;/:*A <"T in order to 0e entitled to the %rivile!es a--orded 0y the 4u0stituted Per-enta!e Ta; eturn/4u0stituted <"T eturn 4ystem %res-ri0ed in the a.oresaid e!ulations> that, this De-laration is su..i-ient authority o. the 2ithholdin! a!ent to 2ithhold @A Final Per-enta!e Ta;/:*A Final <"T .rom my sale o. !oods and/or servi-es) 13 14 Payor/Payor's "uthori3ed e%resentative Payee/Payee's "uthori3ed e%resentative 4i!nature 5ver Printed Name 4i!nature 5ver Printed Name Le!end7 N"6T9 B Non-resident "lien 6n!a!ed in Trade or 9usiness NF# B Non- resident Forei!n #or%oration F#DC B Forei!n #urren-y De%osit Cnit N"N6T9 B Non-resident "lien Not 6n!a!ed in Trade or 9usiness 59C B 5..shore 9an1in! Cnit P6$" B Phili%%ine 6;%ort $one "uthority 49M" B 4u0i- 9ay Metro%olitan "uthority #D" B #lar1 Develo%ment "uthority A $i% 1"8 I# No) (For "lien In-ome e-i%ient 5nly) 0 1 0 7 1 4 449 876 374 416 #5T6L#5, IN#) M"DIL"L" #6NT"L 6L6M6NT"Y 4#E55L 9 4 0 1 W I 320 9I Form No) +@*' Mar-h +**@ (6N#4) M"NC9C"N, M"T"L"M, #5T"9"T5 M"DIL"L", #5T"9"T5 #erti.i-ate o. Final Ta; ,ithheld "t 4our-e Republika ng Pilipinas Kagawaran ng Pananalapi Kawanihan ng Rentas Internas 0 7 3 1 1 4 +)90#:/0+ 3; A/P9A':20RI) %A< )3#0+ 'at(re of Income Payment A % ) I'# )3RP Income %a& ;ringe 8enefit 1 "lien individual em%loyed 0y 59C's, Forei!n Petroleum 4ervi-e #ontra-tors, F 4u0-ontra-tors, ,F @+* F 0y e!ional or "rea Eead8uarters F e!ional 5%eratin! Eead8uarters o. Multinational #o), in-ludin! any o. its Fili%ino em%loyees o--u%yin! the same %osition 2 Payment o. .rin!e 0ene.its to Non-esident "lien Not 6n!a!ed in Trade or 9usiness (N"6T9) ,F @@* 3 6m%loyees other than ran1 and .ile 0ased on the !rossed-u% monetary value ,F @'* Intere$t/=ield from 8an> #epo$it$/#epo$it +(5$tit(te$/.o,ernment +ec(ritie$ 4 4avin! De%osit ,I :': ,# :': 5 Time De%osit ,I :': ,# :': 6 Government 4e-urities ,I :'+ ,# :'+ 7 De%osit 4u0stitutes/5thers ,I :'@ ,# :'@ 8 Forei!n #urren-y De%osits ,I :H* ,# :H* Preterminated Lon! Term De%osit/Investment ,# ??* Less than three (@) years ,I ??* Three (@) years to less than .our (?) years ,I ??: Four (?) years to less than .ive (&) years ,I ??+ All 3ther$ 1" Interest on .orei!n loans %aya0le to NF#s ,# :(* 11 Interest and other in-ome %ayments on .orei!n -urren-y transa-tion /loans %aya0le to 59Cs ,# :I* 12 Interest and other in-ome %ayments on .orei!n -urren-y transa-tion /loans %aya0le to F#DCs ,# :I: 13 #ash dividend %ayment 0y domesti- -or%oration to -iti3en F resident aliens/NF#'s ,I +*+ ,# +:+ 14 Pro%erty dividend %ayment 0y domesti- -or%oration to -iti3ens F resident aliens/NF#'s ,I +*@ ,# +:@ 15 #ash dividend %ayment 0y domesti- -or%) to NF#s 2hose -ountries allo2ed ta; deemed %aid -redit ,# +++ 16 Pro%erty dividend %ayment 0y domesti- -or%) to NF#s 2hose -ountries allo2ed ta; deemed %aid -redit ,# ++@ 17 5n other %ayments to NF# ,# +@* 18 #ash dividend %ayment 0y domesti- -or%oration to N"6T9 ,I ++? 1 Pro%erty dividend %ayment 0y domesti- -or%oration to N"6T9 ,I ++& 2" 4hare o. a N"6T9 in the distri0uta0le net in-ome a.ter ta; o. a %artnershi% (e;-e%t General Pro.essional ,I ++' Partnershi%) o. 2hi-h he is a %artner, or share in the net in-ome a.ter ta; o. an asso-iation, a /oint a--ount or a /oint venture ta;a0le as a -or%), o. 2hi-h he is a mem0er or a -o-venturer 21 Distri0utive share o. individual %artners in a ta;a0le %artnershi%, asso-iation, ,I +?* a /oint a--ount or a /oint venture or -onsortium 22 5ther royalty %ayments to -iti3ens, resident aliens and N"6T9 ,I +&* ,# +&* (other than ,I@(* and ,I @?:) /domesti- and resident .orei!n -or%oration 23 5n %ri3es e;-eedin! P:*,*** F other 2innin!s %aid to individuals ,I +'* 24 9ran-h %ro.it remittan-es 0y all -or%orations e;-e%t P6$"/49M"/#D" re!istered ,# +(* 25 5n the !ross rentals, lease and -harter .ees derived 0y non-resident o2ner or lessor o. .orei!n vessels ,# +I* 26 5n the !ross rentals, lease and -harter .ees derived 0y non-resident lessor o. air-ra.t, ,# @** ma-hineries and other e8ui%ment 27 Payment to 5il 6;%loration 4ervi-e #ontra-tors/4u0-#ontra-tors ,I @:* ,# @:* 28 Payment to Fili%inos or "lien individuals em%loyed 0y Forei!n Petroleum 4ervi-e #ontra-tors/ ,I @+* 4u0-ontra-tors, 5..shore 9an1in! Cnits and e!ional or "rea Eead8uarters and e!ional 5%eratin! Eead8uarters o. Multinational #om%anies o--u%yin! e;e-utive/mana!erial and te-hni-al %ositions 2 Payments to Non-esident "lien Not 6n!a!ed in Trade or 9usiness (N"6T9) e;-e%t on sale o. shares ,I @@* in domesti- -or%oration and real %ro%erty 3" Payments to non-resident individual/.orei!n -or%orate -inemato!ra%hi- .ilm o2ners, lessors or distri0utors ,I @?* ,# @?* 31 oyalties %aid to N"6T9 on -inemato!ra%hi- .ilms and similar 2or1s ,I @?: 32 Final Ta; on interest or other %ayments u%on ta;-.ree -ovenant 0onds, mort!a!es, deeds o. trust or ,I @&* other o0li!ations under 4e-) &H# o. the National Internal evenue #ode o. :IIH 33 oyalties %aid to -iti3ens, resident aliens F non-resident alien en!a!ed in trade or 0usiness (N"6T9) ,I @(* on 0oo1s, other literary 2or1s F musi-al -om%ositions 34 Payments to ta;%ayer en/oyin! Pre.erential Ta; ates/Ta; Treaty ates ,# @I* 35 In.ormer's -ash re2ard to individuals//uridi-al %erson ,I ?:* ,# ?:* 36 Final #a%ital Gains Ta; on 4ale/6;-han!e or 5ther Dis%osition o. eal Pro%erty ,I ?&* ,# ?&* ;or 8($ine$$ %a& 37 <"T ,ithholdin! on Pur-hase o. Goods (2ith 2aiver o. %rivile!e to -laim in%ut ta; -redits) ,< *:? ,< *:? 38 <"T ,ithholdin! on Pur-hase o. 4ervi-es (2ith 2aiver o. %rivile!e to -laim in%ut ta; -redits) ,< *+? ,< *+? 3 Person e;em%t .rom <"T under 4e-) :*I (3) (2ith 2aiver o. %rivile!e to -laim in%ut ta; -redits) ,9 *(? ,9 *(? 4" ,9 :I: 41 Ta; on ,innin!s and Pri3es on horse ra-es/o2ners o. 2innin! ra-ehorses (4e-) :+') - Gov't) ,ithholdin! "!ent (:*A) ,9 :I+ 42 ,9 :I@ 43 Ta; on ,innin!s and Pri3es on horse ra-es/o2ners o. 2innin! ra-ehorses (4e-) :+' ) - Private ,ithholdin! "!ent (:*A) ,9 :I? 44 <"T ,ithholdin! on Non-residents - Gov't) ,ithholdin! "!ent ,< *?* 45 <"T ,ithholdin! on Non-residents - Private ,ithholdin! "!ent ,< *&* Ta; on ,innin!s and Pri3es (4e-) :+') (double/forecast/quinella/trifecta 0ets) - Gov't) ,ithholdin! "!ent (?A) Ta; on ,innin!s and Pri3es (4e-) :+' ) (double/forecast/quinella/trifecta 0ets) - Private ,ithholdin! "!ent (?A)