AFFIDAVIT - DECLARATION OF CURRENT YEAR’S GROSS INCOME Republic of the Philippines ) Province of ) City/Municipality of ) 1 also known as of legal age. single/manied, residing at alter being swom in accordance with law, depose and say that: 1. I receive professional / talent / service fees as (please check box/es) J / Practice of Profession / / Management & Technical Consultants Professional Entertainment Bookkeeping agents and agencies / / Professional Athlete / / Other recipients of talent fees / (Director / Director who is not employee of the company / | Others: Specify / Judicial person in the practice of profession 2. As such, I have received a gross income of P for the current year as of. 3. I am executing the Affidavit-Declaration as a requizement of Revenue Regulations No, 30-2003 of the Bureau of Internal Revenue in the determination, of the applicable creditable withholding tax rate (10% or 15%) to be imposed by withholding agent. IN WITNESS WHEREOF, I ha in the Municipality hereunto set my hand this day of province of Philippines. Affiant — Declarant TIN: SUBSCRIBED AND SWORN to before me, in this day of, with Community Cettificate No. issued at on 20, Doe. No, Page No, Book No. Series of 20