Annex "C"

SWORN DECLARATION

REPUBLIC OF THE PHITIPP]NES

PROV]NCE OF

CIfY/MU NICIPALITY OF

l, lNome af Authorized Representotive), \Notionolitv), of legal age desiSnated as (Postior) of

(Reoistered Nome of componv/Cotporotion), with business address located at
do herebv certify the follow ng:

submltted
That in compliance with the reqLrlrements of Revenue Regulations No.-,
(Nurnber
j!3M!L--ElB_lEPlE
herewith is/are
of DVD R/s) containing lllllbei--ql
2307/2316) covering the period mm/dd/wv.

z That the

of the

DVD-Rs being submitted herewith conform

requirements
set by the Bureau of lnternal Revenue.
conditions/specification

contents

to

the

That the soft copies of the BIR Form 2307/2316 contained in the DVD-R/S being submitted
herewith are the complete and exact copies of the original thereof.

HEREBY DECLARE UNDER THE PENALTIES OF PERJURY THAT THE FOREGOING

ATTESTATIONS ARE TRUE AND CORRECT.

Name and signature of Authorized

Representative
TIN:
SUBSCRIBED and sworn

of

_,

20_

Notary public
Doc. No.
Pag-. No.
Book No.
Serles of

'tr

by

al

to before me, in the City/Municipallty of

with Residence Certificate No.

this day
issLred at

2a

0l' lNlliliN/J RrlE)arn

RECORDS MGT. NIVISION

BURIAU

{t} r, r 206

0t

? a lnt

R.ECEtrVED