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40B Particulars Agency 40C Number 41B MM 41C DD 41D YYYY Amount
1700
DLN:
For Individuals Earning Compensatio n Income (Including Non-Business / Non-Profession Related Income)
1 For the Year (YYYY) 2 Amended Return Yes
I I 0 11 I I 0 40 I I 0 41
Part I n
Informatio Spouse 7 TIN 10 12 8 RDO Code Spouse's Name (Last Name, First Name, Middle Name) Registered Address 17 Zip Code 18 Telephone Number
5 9
TIN
6 RDO Code Taxpayer's Name (Last Name, First Name, Middle Name)
Married
19A Number of Qualified Dependent Children Computation of Tax 20A 21A 22A 23A
19B Is the wife claiming the additional exemption for qualified dependent children? Yes Taxpayer/Filer Spouse 20B
No
20 Gross Taxable Compensation Income (Schedule 1) Other Taxable Income (Non-business/Non-profession Income
Including Net Income of Marginal Income Earners)
21 22 23 Gross Taxable Income (Sum of Items20A,21A,22A/20B,21B,22B) 24 Less:Total Personal & Additional Exemptions (Schedule 2)
24A Premium paid on health and/or hospitalization insurance not to exceed P2,400 per year. (See Instructions) 24C 24E 25A 26A 26C 27A 27C 27E 27G 28A 29A 29C 29E 29G 30A 30C 31 32 27B 27D 27F 27H 28B 29B 29D 29F 29H 30B
Total (Sum of Items 24A & 24C/24B & 24D) 25 Taxable Income (Item 23A less Item 24E/ Item 23B less Item 24F) 26 Tax Due 27 [Aggregate Tax Due - (Sum of Items 26A and 26B)] Less:Tax Credits/Payments Tax Withheld Per BIR Form No. 2316 Foreign Tax Credits Tax Paid in Return Previously Filed, if this is an amended return Total Tax Credits/Payments (Sum of Items 27A,27C,27E/27B,
27D, 27F)
28 29
Tax Payable (Overpayment)(Item 26A less Item 27G/ Item 26B less Item 27H)
Add: Penalties Surcharge Interest Compromise Total Penalties (Sum of Items 29A,29C & 29E/29B,
29G / 28B & 29H) Aggregate Amount Payable/(Overpayment)(Sum of Items 30A & 30B) 31 Less: Amount Paid in this Return/First Installment 32 Amount Still Due on or before July 15, if taxpayer is allowed to pay by installment
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 regulations issued under authority thereof. ` 33 Taxpayer/Authorized Agent (Signature over Printed Name) Community Tax Certificate No. Place of Issue Date of Issue (MM/DD/YYYY) Amount 37 34 35 36 Stamp of Receiving Part III Details of Payment
38
Machine Validation/Revenue Official Receipt Details (If not filed with the bank)
Schedule 1
Schedule 2
30,000 70,000
Note : Effective January 1, 1999, the maximum rate will be changed to 33% and 32% on January 1, 2000.