ANNEX A BIR Form No.

______

APPLICATION FOR PRODUCT REPLENISHMENT CERTIFICATE

(Pursuant to Revenue Regulations No. ________ dated ________) TO: The Chief, LT- Field Operations Division Rm. 801, BIR, Diliman, Quezon City
APPLICANT Date of Filing___________

PART I.

Taxpayers Name____________________________________________________________________ Plant Address:_________________________________________________________Zip Code______ Taxpayer Identification No. ________________________Assessment No._______________________ Home RDO Code _________ Telephone/Mobile Phone No.___________________________________ E-mail address:______________________________________________Fax No.__________________ PART II. DETAILS OF PRODUCTS APPLIED FOR REPLENISHMENT
Quantity
Volume Unit of measure

Product Description/Brand Name/Model

Excise Tax Due P

TOTAL

PART III.

ATTACHED DOCUMENTARY REQUIREMENTS

For Direct Export Transactions: Export Permit of product applied for replenishment Proof of payment of the excise tax paid on the product Purchase order Sales invoice and delivery receipt duly acknowledged by the purchaser or his authorized representative Packing list Bill of lading Withdrawal Certificate, Official Delivery Invoice or any BIR-prescribed forms to document removal of excisable articles from the place of production Inward remittance of the export proceeds in accordance with the rules and regulations of the Bangko Sentral ng Pilipinas (BSP) and details thereof, in appropriate cases Certificate of Loading issued by the Bureau of Customs (BOC) Certified true copy of the container scanners report and film negative issued by the BOC Batch liquidation statements indicating receipts and removals Others, please specify ________________________________________________ Sale/Delivery to International Carriers Proof of reciprocity agreement duly attested by the Department of Foreign Affairs (DFA)
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Bilateral air agreement with the foreign country of destination, in case of international airlines Certificate of Registration issued by the Maritime Authority of the Philippines (MARINA) certifying that the marine vessel is exclusively engaged in the international shipping Sales invoice and delivery receipt duly acknowledged by the purchaser or his authorized representative Purchase order or supply agreement Proof of payment of the excise tax Withdrawal Certificate, Official Delivery Invoice or any BIR-prescribed forms to document removal of excisable articles from the place of production Batch liquidation statements indicating receipts and removals Proof that excise tax was not billed to the customer Others, please specify _________________________________________________________

Sale/Delivery to Entities Registered in Freeport/Economic Zones (PEZA, SBMA, etc)

Certificate of Registration duly issued by the Regulatory Authority of the freeport/economic zone Certificate of Good Standing duly issued by the appropriate government regulatory agency for the covered period Sales invoice and delivery receipt duly acknowledged by the purchaser or his authorized representative Purchase order or supply agreement Proof of payment of excise tax Withdrawal Certificate, Official Delivery Invoice or any BIR-prescribed forms to document removal of excisable articles from the place of production Batch liquidation statements indicating receipts and removals Proof that excise tax was not billed to the customer Certified true copy of the gate pass documenting the entry of the article in the secured area of the freeport/economic zone Certification duly issued by the appropriate government regulatory agency that the article did not subsequently enter the customs territory. Others, please specify_________________________________________________________

PART III.

PERJURY DECLARATION

I declare, under penalties of perjury, that this application including the accompanying documents, has been made in good faith, verified by me and to the best of my knowledge and belief, is true and correct, and that all accompanying documents, if any, are valid. ________________________________ Applicants signature over printed name Position:_________________________ ___________________________________________________________________________________ For BIR Use:
Stamp of Receiving Office Stamp ofof Receiving and Date ReceiptOffice
and Date of Receipt

Application Form No._________________ Remark/s: ____________________________ ____________________________ Reviewed by: _______________________________ Name & Signature of Revenue Officer

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