:or BIR BCS/

Republic of the Philippines

Department of Finance
Aranex "4"
Jse Only ltem: Bureau of lnternal Revenue

BIR Form No
Tax Amnesty Return
2118-DA on De!inqLlencies Illl ffiffii[.#Ffl[ffiillllI
March 2019
Page 1
Pursuant to Republic Act No. 11213 21 1 8-DA C3/1 I P1
Enlet all requied infarmailon in CAPITAL LEIIERS uslng BLACKink. Mark all applicable baxes vtith an'l'
iled 2 Tax Tvpe Code 5 No. of Sheetis Aitached
Tax Amnesty
'art l- Ta lnformation
I

| 6 Taxpayer ldentiflcation Number (r/v)

8 Taxpayer/Filer's Namellqqt Name, First Name, Middte for tndividual OR Reg/stered N ame for Non-tndiviaui,aiil
I

illillllllirlirltitli-,]_i
i 9 Registered Address frnoicat"mrpter"rooo"s rhvmi,rura.r*tror,raorssfre,egdurdrdd"oudf"od,to;d*or;tsdd@ERFcrmM 1ir 5

iili 9A ZIP Code

, aA r--tt
I IU EIIIAII AUUIUSli ll I

Part ll - C of Tax Am
Amount of Tax

{1 Delinquent Accounts and Assessments which have become final and executory From Paft V ttem 12)

12Tax Cases subject of flnal and executory judgment by the courts (From pai V ttem 1g)

13 Pending Criminal Cases filed with the Department of Justice (DoJ)/Prosecutor's Office or the courts foaiax-
evasion and other criminal offenses under Chapter ll of Title X and Section 275 of the Tax Code, as amended

14 Wiihholding Agents whowithheld taxes but failed to remit the same to the Bureau (From Paft V ttem 33)

'15 Total Tax Amnesty Amount (Sum of /tems 11 to 14) (Amountto be reflected in BIR Form No 0621-DA)

For lndiv;dual: For Non-lndrvidual

Signature over Printed, Name of Taxpayer/Authorized Representative/Tax Agent Signature over Printed
{l ndicate Title/Designatian and TIN} Authorized Officer or
Agent Accreditation Number/ Date of lssue

Part lll - Attachments

0621-DA (duly stamped received by the RCO or AAB) with duly validated deposit stip
L_.1 Certiflcate of Delinquencies
E lssued by RDO I lssued by LTCED
f] lssued by Legal Division D lssued by LTD - Cebu
I Issued by Litigation Division r-l lssued by LTD - Davao
I lssued by Prosecution Division
E Copy of FAN/FLD with details, if applicable

Part lV - Details of Pa
Faid thrii:
TAAB 6peciry) Branch Locatroir Date tuu'oDrry't ' __
flel) t:aeabt narne) Date yntuaanrrrl

n !,'''
ft'l
APR *,i 2019
r!: {i,r p s1
','l ; '{:i.'i
 BIR Form No.
Tax Amnesty Return
2118-DA
March 2019
on Delinquencies
Pursuant to Republic Act No. 11213

ay€.s.erd Issessmant which became final and

lifred fom the Ceftiftcate of Tax
WflXI

It2Total (Sumof ltajir,s'11o 11){ToPatll ltem 11)

criminal''affenses