Annex "C"

Republic of the Philippines

Deparlment of Finance
BUREAU OF INTBRNAI- REVENUE
Quezon CitY

CERTIFICATE OF TAJ( DELINQUENCIES/TAX LIABILITIES

This is to certify that based on the record ofthis Bueau, 0{AME OF TAXPAYER) , with Taxpayer Identification Number (TIN)
000-000-00Q ard registered address at Dililge4JQ!9ZgE Q!q, has the fotlowing delinquent tax liabilities:

TAX T,AXABLE PERIOD FAN/FLD/ DATE OF RECEIPT PARTIAL PAYMtrNT**

FDDA # OF FAN/FLD/FDDA TOTAL
TYP}i* FROM TO
mmidd/yyyy Or (Not applicable on Csses
BASIC TAX PENALTIES TOTAL AMOTINT MANNBR**
rnrn/dd/yyyy pending with DOJ/Prosecutor's
PAN # OR Olfice/Courts)
CASE #
I IT 01t01/2016 12131120r6 123456 03ltsl2018 1.000.000 300,000 I.300.000 100.000 CSA
2 VT

+Td Type Codes: lT{ncome Tdi vT_Value Add.d Td; Ds-Docum€ntary Stamp Tax
*+Mun;;r ofpanial payments: Alp-Approv€d Inslallmont Plan; CSA- Compromis€ Seul€m€nt Application; APA- Abatemmt ofPeElry Applic.tion; PAp- pm"Fd' 'f
Auction€d l,rcpcny/ies; MBP- Minimum Bid Pri@ of ProPerties forfeited in favo. ofthe Sovernment far lack oI bidder

This Certification is issued for purposes oftaxpayer's intention to avail ofthe Tax Amnesty on Tax Delinquencies pursuant to
Republic Act No. 11213, as implemented by Revenue Regulations No.

this

-.
(Signature over Printed Name)
REVENUts DISTRICT OFFICER / CHIEF, PROSECUTION DIVISION
CHIEF" LEGAL DIVISION/ CHIEF, LITIGATION DIViSION
RDO No. _, / REVENUE REGICN NO.

20 1 9-RDO f'r:. i,:i{ }fl.tce Code-000001