AFFIDAVIT OF SELF-EMPLOYED PROFESSIONAL

REPUBLIC OF THE PHILIPPINES)

Province of _______________ ___)
City/Municipality of ________ ___)

I, _______________________, Filipino, of legal age, married to _______________________, and a resident of

____________________________________, after having been duly sworn in accordance with law, depose and
state that:

1. That I am a _______________________ with TIN _______________________, duly registered with the

Bureau of Internal Revenue under RDO _______________________ and practicing my profession in my
office address at _______________________.

2. That as a Licensed Insurance Agent, I render professional services to the following Companies:
1. Corporation

3. I am executing this Affidavit – Declaration as a requirement of Revenue Regulations No. 4 - 2014 of the
Bureau of Internal Revenue indicating the rates, manner of billings and the factors I consider in
determining my professional/service fees.

4. That my professional/service fees are variable depending on the agreement with the Insurance
Companies, insurance premium, commission rates and volume of production.

5. Fees are collected after service is rendered according to the agreed terms and conditions.

6. More or less, the following rates are applied per line:

6.1 Fire Insurance ranges from Php 100.00 to ____________

6.2 Motor Insurance ranges from Php 25.00 to ____________
6.3 Marine and Aviation Insurance ranges from Php 160.00 to ______________
6.4 Personal Accident Insurance ranges from Php 300.00 to ___________
6.5 Liability Insurance ranges from Php 150.00 to ___________________
6.6 Engineering Insurance ranges from Php 375.00 to PhP ___________
6.7 Bonds/Surety ranges from Php 55.00 to ____________________

7. This affidavit is hereby executed to attest to the truth of the facts above-stated, and in compliance with
the dictates of BIR Revenue Regulations No. 4-2014.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ________ day of ____________, in the
city/municipality of ______________, province of _______________, Philippines.

___________________________
Affiant – Declarant

SUSCRIBED AND SWORN TO before me, a notary public in and for _______________________________, this
________ day of _______________ 20___. The affiant, whom I identified through the following competent
evidence of identity: _______________________, valid until _______________________ issued by
_______________________, personally signed the foregoing instrument before me and avowed under penalty of
law to the whole truth of the contents of said instrument.

NOTARY PUBLIC My Commission expires on _____________

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