(To be filled up by the BIR) DLN:

Republika ng Pilipinas Kagawaran ng P ananalapi

Taxpayer PSOC:

PSIC:

Spouse PSOC:

PSIC:
B Form N IR o.

Kawanihan ng Re ntas In ternas

For S elf-E ployed, E m states, and Trusts (Including those w both B ines & C pens / us s om ationIncom e)

Annual Incom e Tax R eturn

X Yes No Background Information
6 9 TIN 3
Spouse

1701
July, 19 ( 99

E NCS

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

For the Year (YYYY)

2010
Taxpayer/Filer

2 Amended Return?

No. of sheets attached

Part I 4 8 TIN

278

878

445

RDO Code

Taxpayer's Name (For Individuals)(Last Name, First Name, Middle Name) (Estates & Trusts)

7 RDO Code Spouse's Name (Last Name, First Name, Middle Name) (If applicable)

SALAS, NARCISO FRANCO JR.

10 Registered Address 11 Registered Address 13 Zip Code 19 ATC
14 Telephone Number

STO. TOMAS, SAN LUIS, PAMPANGA

12 Date of Birth (MM/DD/YYYY) 15 Date of Birth (MM/DD/YYYY) 20 Line of Business/Occupation 16 21 Zip Code 17 ATC Telephone Number Compensation Business

09

18

1941
Compensation Business

18 Line of Business/Occupation

BUSINESSMAN
22 Method of Deduction Itemized Deduction X 24 Exemption Status Single Head of the Family

Mixed Income Mixed Income 10 % 23 Method of Deduction 10 % Optional Standard Deduction Itemized Deduction Optional Standard Deduction 24A Number of Qualified 24B Is the wife claiming the additional exemption for qualified dependent children? Married Dependent Children Yes No Yes
Taxpayer/Filer

25 Are you availing of tax relief under Special Law/International Tax Treaty? Computation of Tax Part II 26 Gross Taxable Compensation Income (Schedule 1) Less: Deductions 27
Premium paid on health and/or hospitalization Insurance not to exceed P2,400 per year. 26A 27A 27C 27E 28A 29A 30A 31A 32A 33A 34A

No

If yes, specify
Spouse

26B 27A 27C 27E 28A 29A 30A 31A 32A 33A 34A 35A 27B 27D 27F 28B 27B 27D 27F 28B 29B 30B 31B 32B 33B 34B 35B 36B 37B 38B 39B

Personal and Additional Exemptions

Total Deductions (Sum of 27A & 27C/27B & 27D)

50,000.00 (50,000.00) 412,454.50 (245,887.25) 166,567.25 166,567.25 (95,995.45) 70,571.80 (50,000.00) ) 20,571.80 56,000.00 20,571.80 1,557.18
39C 39C

28 Taxable Compensation Income/(excess of Deductions over Taxable

Compensation Income) (26A less 27E/26B less 27F)

29 Sales/Receipt/Revenues/Fees (Schedule 2) 30 32 Less: Cost of Sales/Services (Schedule 3/4) Add: Other Taxable Income (Schedule 5) 31 Gross Taxable Business/Profession Income (29A less 30A/29B less 30B) 33 Total (Sum of 31A & 32A/31B & 32B) 34 Less: Allowable Deductions
Optional Standard Deductions(Sch. 6) or Itemized Deductions (Sch. 7)

29B 30B 31B 32B 33B 34B 35B 36B 37B 38B 39B

35A 35 Net Income (33A less 34A/33B less 34B) Less: Excess of Deductions over Taxable Compensation Income (from 36 Item 28A/28B) or the total deductions under line 27E/27F,

if there is no compensation Income

36A 37A 38A 39A

37 Taxable Business Income (35A less 36A/35B less 36B) 38 Total Taxable Income(Sum of Items 28A & 37A/28B & 37B if
line 28 results to taxable income, otherwise, 37A/37B)

37A 38A 39A

39 Tax Due 40 [Aggregate Tax Due (Sum of Items 39A & 39B)] Less: Tax Credit/Payments 40A/B Prior Years' Excess Credits
40C/D Tax Payments for the First Three Quarters 40E/F Creditable Tax Withheld for the First Three Quarters
40G/H Creditable Tax Withheld Per BIR Form 2307 for the 4th Qtr.

1,557.80
40B 40D 40F 40H 40J 40L 40N 40P 41B 42B 42D 42F 42H 40B 40D 40F 40H 40J 40L 40N 40P 41B 42B 42D 42F 42H 43B

40A 40C 40E 40G 40I 40K 40M 40O 41A 42A 42C 42E 42G 43A

40A 40C 40E 40G 40I 40K 40M 40O 41A 42A 42C 42E 42G 43A

40I/J Tax Withheld Per BIR Form 2316 40K/L Foreign Tax Credits
40M/N Tax Paid in Return Previously Filed, if this is an Amended Return 40O/P Total Tax Credits/Payments(Sum of 40A,C,E,G,I,K,M/40B,D,F,H,J,L,N )

41 Tax Payable (Overpayment) (Item 39A less 40O/39B less 40P) 42 Add: Penalties Surcharge Interest Compromise Total Penalties (Sum of Items 42A,C,E/42B,D,F) 43 Total Amount Payable/ (Overpayment) (Sum of Items 41A,42G/41B, 42H) If overpayment mark one box only:
Part III Particulars Drawee Bank/ Agency

1,557.18
43C

43B 43C

Aggregate amount Payable/(Overpayment)(Sum of Items 43A & 43B) To be refunded

Details Number of Payment Date MM DD YYYY

1,557.18
To be carried over as tax credit next year/quarter Stamp of Receiving Office and Date of Receipt

To be Issued a Tax Credit Certificate

Amount

44 Cash/Bank Debit Memo 45 Check 45A 46 Tax Debit Memo 47 Others

47A

44 45D 46C 47D

45B 46A 47B

45C 46B 47C

Machine Validation/Revenue Official Receipt Details (If not filed with the bank)

Particulars 76 Advertising 77 Rental 78 Insurance 79 Royalties 80 Repairs and Maintenance 81 Representation and Entertainment 82 Transportation and Travel 83 Fuel and Oil 84 Communication, Light and Water 85 Supplies 86 Interest 87 Taxes and Licenses 88 Losses 89 Bad Debts 90 Depreciation 91 Amortization of Intangibles 92 Depletion 93 Charitable Contribution 94 Research and Development 95 Amortization of Pension Trust Contribution 96 Miscellaneous 97 Total Allowable Expenses not to

Schedule of Itemized Deductions (continuation) Taxpayer/ Filer

Spouse

exceed the sum of Items 31 & 32 (To Items 34A & 34B) Section C Reconciliation of Net Income Per Books Against Taxable Income Taxpayer/Filer 98 Net Income/(Loss) per Books 99 Add: Other Taxable Income/Non-deductible Expenses Spouse

100 Total (Sum of Items 98 and 99 ) 101 Less: Non-taxable Income and Income Subjected to Final Tax

102

Special Deductions

103

Total (Sum of Items 101 and 102)

104 Net Income/(Loss) Before Premium on Health and Hospitalization Insurance and Exemptions (To Item 35) Section D Qualified Dependent Children
Name Birth Date (MM/DD/YYYY) Name Birth Date (MM/DD/YYYY)

Other Dependents (to be acomplished if taxpayer is Head of the Family) Name Birth Date (MM/DD/YYYY) Relationship to Taxpayer

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. 105

Narciso F. Salas Jr.

Taxpayer/Authorized Agent Signature over Printed Name Place of Issue 108 109

106

Owner
Title/Position of Signatory Date Issued DD YYYY 110 Amount

Community Tax Certificate Number 107

MM

919

095

328