(To be filled up by the BIR) Document Locator Number (DLN): _____________________________ Republika ng Pilipinas Kagawaran ng Pananalapi

Batch Control Sheet (BCS) No./Item No.: __________________________________

Kawanihan ng Rentas Internas All information must be written in CAPITAL LETTERS

Fill in alll blank spaces. Shade all applicable circles.

Annual Income Tax Return

[For Self-Employed Individuals, Estates and Trusts (Including those with both Business and Compensation Income)]

BIR Form No.

1701
November 2011 (ENCS)

TO BE FILED IN THREE (3) COPIES: (1) BIR FILE COPY (2) BIR ENCODING COPY (3) TAXPAYER FILE COPY

1 For the year (YYYY) Part 1

Amended Return?

Yes

No

Joint Filing?

Yes

No

Background Information Taxpayer/Filer

4 Taxpayer Identification Number (TIN) 6 Taxpayer's Name 7 Registered Address

0 S

6 H O

0 E U

RDO Code

W 4 T

N N

G A D R A R N A G S S T O R R E A
Phase Number

R T H

L
First Name Middle Name

G Q

R U

E E

E Z

N O

P N

R C

K I T

V Y

L .

(Unit/Room Number/Floor)

(Building Name)

(Lot Number

Block Number

House/Building Number)

(Street Name)

.
(Subdivision/Village) (Barangay)

(Municipality/City) 8 Date of Birth (MM/DD/YYYY) 11 Contact Number 13 Line of Business 15 Method of Deduction Itemized Deduction [Secs. 34 (A to J), NIRC] 9 Gender

(Province)

(Zip Code) Separated Widow/er

Male

Female

10 Civil Status

Single

M Married

12 E-mail Address 14 Alphanumeric Tax Code (ATC) Optional Standard Deduction (OSD) - 40% of Gross Sales/Receipts/ Revenues/ Fees [Section 34(L), NIRC, as amended by R.A. No. 9504] Spouse

II 011

Compensation Income

II 012

Business Income/Income from Profession Yes No

II 013

Mixed Income

16 Claiming for Additional Exemptions?

17 If yes, number of Qualified Dependent Children

18 Spouse's Name Last Name 19 Taxpayer Identification Number (TIN) 21 Date of Birth (MM/DD/YYYY) 24 Line of Business 26 Method of Deduction
29 -

First Name 20 RDO Code 23 E-mail Address 25 Alphanumeric Tax Code (ATC) Optional Standard Deduction (OSD) - 40% of Gross Sales/Receipts/ Revenues/Fees [Section 34(L), NIRC, as amended by R.A. No. 9504] II 011 Compensation Income II 012 Business Income/Income from Profession Yes No

Middle Name

22 Contact Number

II 013

Mixed Income

Itemized Deduction [Secs. 34 (A to J), NIRC]

27 Claiming for Additional Exemptions?

28 If yes, number of Qualified Dependent Children

Qualified Dependent Children Last Name First Name Middle Name Date of Birth (MM/DD/YYYY) Mark, if Physically/Mentally Incapacitated

1 2 3

3 4 30 Are you availing of tax relief under Special Law or International Tax Treaty? Yes No

BIR Form No. 1701 - page 2

Part II 31 Income Tax Due under Regular Rate (from Item 69C/ 69D of Part V) 32 Add: Income Tax Due under Special Rate (from Item 69A/ 69B of Part V) 33 Total Income Tax Due (Sum of Items 31A & 32A/ 31B & 32B) 34 Aggregate Income Tax Due (Sum of Item 33A & 33B) 35 Less: Tax Credits/Payments (attach proof) 35A/B Prior Year's Excess Credits 35C/D Tax Payment for the First Three Quarters 35E/F Creditable Tax Withheld for the First Three Quarters 35G/H Creditable Tax Withheld per BIR Form No. 2307 for the 4th Quarter 35I/J Tax withheld per BIR Form No. 2316 35K/L Tax Paid in Return Previously Filed, if this is an Amended Return 36M/N Foreign Tax Credits 35O/P Other Payments/Credits, specify____________________________ 35Q/R Total Tax Credits/Payments (Sum of Items 35A, C, E, G, I, K, M & O/ 35B, D, F, H, J, L, N & P) 36 Net Tax Payable/(Overpayment) (Item 33A less 35Q/ 33B less 35R) 37 Aggregate Tax Payable/(Overpayment) (Sum of Item 36A & 36B) 38 Add: Penalties 35A 35C 35E 35G 35I 35K 35M 35O 35Q 36A Computation of Tax Taxpayer/Filer 31A 32A 33A Spouse

2 0

31B 32B

4
34

2 0

33B

2 0

35B 35D

9 3

1 7

0 8

8 0 8 0

0 0

35F 35H 35J 35L 35N 35P

2 1
37

8 5

9 8

6 0 6 0

0 0

35R 36B

6 0

Taxpayer/Filer 38A
Spouse 38E

38B 38F

38C 38G

38D

38H 39

39 Aggregate Penalties (Sum of Item 38D & 38H) 40 Total Amount Payable/(Creditable/Refundable) (Sum of Item 36A & 38D/ 36B & 38H) 41 Aggregate Amount Payable/(Creditable/Refundable) (Sum of Item 40A & 40B) 42 Less Portion of Tax Payable Allowed for 2nd Installment Payment to be paid on or before July 15 (not less than 50% of Item 33A/ 33B) 43 Amount of Tax Required to be Paid Upon Filing this Return (Item 40A less 42A/ 40B less 42B) 44 Net Aggregate Amount of Tax Required to be Paid/(Creditable/Refundable) Upon Filing of this Return (Sum of Item 43A & 43B) If overpayment, mark one box only: Part III 45 Total Tax Relief/Savings (from Item 98J/ 98K of Part VII) 46 Aggregate Amount of Tax Relief/Savings (Sum of Item 45A & 45B) Part IV Particulars Cash/Bank 47 Debit Memo Details of Payment Drawee Bank/Agency 47A 47B Number 47C Date (MM/DD/YYYY) 47D To be Refunded To be issued a Tax Credit Certificate (TCC) To be carried over, as tax credit for the next year/quarter Availment of Tax Income Incentives/Exemptions 42A 43A 40A

1
41

6 0

40B

44

42B 43B

6 0

Taxpayer/Filer 45A 46

Spouse

45B

Stamp of Receiving Office/AAB and Date of Receipt

Amount

(RO's Signature/Bank Teller's Initial)

48 Check 49 Tax Debit Memo 50 Others

48A

48B 49A

48C 49B 50C

48D 49C 50D

50A

50B

BIR Form No. 1701 - page 3

Part V Taxpayer/Filer 51 Gross Compensation Income (from Schedule 1) 52 Less: Non-Taxable/Exempt Compensation 53 Gross Taxable Compensation Income (Item 51A less 52A/ 51B less 52B) 54 Less: Deductions 54A/B Premium on Health and/or Hospitalization Insurance (not to exceed P 2,400/year) 54C/D Personal Exemption/Exemption for Estate and Trust 54E/F Additional Exemption 54G/H Total Deductions (Sum of Items 54A, C & E/ 54B, D & F) 55 Total Compensation Income/(Excess of Deductions) (Item 53A less 54G/ 53B less 54H) 56 Sales/Revenues/Receipts/Fees (net of sales returns, allowances and discounts) 57 Add: Other Taxable/Exempt Income from Operations, not subject to Final Tax
56A 54A 54C 54E 54G 55A

Breakdown of Income (attach additional sheet/s, if necessary) EXEMPT SPECIAL RATE Spouse Taxpayer/Filer

Spouse
51A 52A 53A

REGULAR Taxpayer/Filer

RATE Spouse

4 8 8 9 6 0 4 8 8 9 6 0 4 8 8 9 6 0 4 8 8 9 6 0 3 3 9 0 5 0

51B 52B 53B

54B 54D 54F 54H 55B

56B

56C

56D

56E

0 0 56F
57F 57L 57R

57A/B/C/D/E/F
57G/H/I/J/K/L

57A 57G 57M 58A 59A 60A 61A 62A

57B 57H 57N 58B 59B 60B 61B 62B

57C 57I 57O 58C 59C 60C 61C 62C

57D 57J 57P 58D 59D 60D 61D 62D

57E 57K 57Q 58E 59E 60E 61E 62E

57M/N/O/P/Q/R Total (Sum of Item 57A & 57G/ 57B & 57H/ 57C & 57I/ 57D & 57J/ 57E & 57K/ 57F & 57L)
58 Total Sales/Revenues/Receipts/Fees (Sum of Item 56A & 57M/ 56B & 57N/ 56C & 57O/ 56D & 57P/ 56E & 57Q/ 56F & 57R) 59 Less: Cost of Sales/Services 60 Net Sales/Revenues/Receipts/Fees (Item 58 less 59) 61 Add: Non-0perating Taxable Income 62 Gross Income (Sum of Item 60 & 61) 63 Less: Deductions 63A/B Optional Standard Deduction (OSD) OR 63C/D/E/F/G/H Regular Allowable Itemized Deductions Special Allowable Itemized Deductions Description 63I/J/K/L/M/N 63O/P/Q/R/S/T 63U/V/W/X/Y/Z Allowance for NOLCO (from Item 83) Legal Basis

0 0 58F
59F

0 0 60F
61F

0 0 62F
63B

63A

63C

63D

63E

63F

63G

0 0 63H

63I 63O 63U 63AA 64A

63J 63P 63V 63AB 64B

63K 63Q 63W 63AC 64C

63L 63R 63X 63AD 64D

63M 63S 63Y 63AE 64E 65A

3 3 9 0 5 0 1 4 9 9 1 0 5 0 0 0 0 9 9 9 1 0

63N 63T 63Z

68D

Total Allowable Itemized Deductions (Sum of Items 63C, I, O & U/ 63D, J, P & V/ 63E, K, Q & W/ 63F, L, R & X/ 63G, M, S & Y/ 63H, N, T & Z) Net Income (Item 62A less 63AA/ 62B less 63AB/ 62C less 63AC/ 62D less 63AD/ 64 62E less 63AE/ 62F less 63AF) (to Item 90 of Part VI-Schedule 3) Less: Excess of Deductions over Taxable Compensation Income (from Item 55A/55B) 65 63AA/AB/AC/AD/AE/AF

0 0 63AF 0 0 64F 0 0 65B 0 0 66F

OR the Total Deductions (from Item 54G/54H) , if there is no Compensation Income

66 Taxable/Exempt Business Income/Income from Profession (Item 64 less 65) 67 Total Taxable Income (Sum of Item 55 & 66) 68 Applicable Tax Rate (i.e. special/regular rate) 69 Income Tax Due (refer to Tax Table below) (to Item 32A & 32B/ 31A & 31B) 70 Less: Share of Other Agencies 71 Income Tax Due to National Government Under Special Rate (Item 69A less 70A/ 69B less 70B)

66A 67A

66B 67B

66C 67C 68A 69A 70A 71A

66D 67D 68B 69B 70B 71B

66E 67E

9 9 9 1 0 0 0 67F 68C % 1 4 4 8 2 0 0 69D

69C

If Taxable Income is: Not over P 10,000 Over P 10,000 but not over P 30,000

Tax Due is: P 5% 500 + 10% of the excess over P 10,000

TAX TABLE If Taxable Income is: Over P 140,000 but not over P 250,000

Tax Due is: P 22,500 + 25% of the excess over P 140,000

Over P 30,000 but not over P 70,000 Over P 70,000 but not over P 140,000

P 2,500 + 15% of the excess over P 30,000 P 8,500 + 20% of the excess over P 70,000

Over P 250,000 but not over P 500,000 Over P 500,000

P 50,000 + 30% of the excess over P 250,000 P 125,000 + 32% of the excess over P 500,000

NOTE: Read Guidelines and Instructions on page 6

- THIS FORM IS NOT FOR SALE -

BIR Form No. 1701 - page 4

Part VI Schedule 1 Name of Employer 72 73 74 75 Total Compensation Income/Tax Withheld (Sum of Item 72 to 74) (to Item 51) Schedule 2 76 Gross Income 77 Less: Total Deductions exclusive of NOLCO & Deductions under Special Laws 78 Net Operating Loss Carry Over (to Schedule 2A) Schedule 2A Net Operating Loss Year Incurred 79 80 81 82 79A 80A 81A 82A Amount 79B 80B 81B 82B Computation of Available Net Operating Loss Carry Over (NOLCO) (attach additional sheet/s, if necessary) Net Operating Loss Carry Over (NOLCO) Applied Previous Year Applied Current Year SCHEDULES Gross Compensation Income and Tax Withheld (attach additional sheet/s, if necessary) TAXPAYER/FILER Taxpayer Identification Number (TIN) Compensation Income 72A 73A 74A 72B 73B 74B 75A Computation of Net Operating Loss Carry Over (NOLCO) 76 77 78

SPOUSE Tax Withheld Compensation Income Tax Withheld 72E 73E 74E 75D 72D 73D 74D 75C

72C 73C 74C 75B

Expired

Net Operating Loss Unapplied

79C 80C 81C 82C 83

79D 80D 81D 82D

79E 80E 81E 82E

83 Total (Sum of Items 79C, 80C, 81C & 82C) (to Item 63U/V/W/X/Y/Z) Schedule 3

Reconciliation of Net Income per Books Against Taxable Income (attach additional sheet/s, if necessary) Special Rate Taxpayer/Filer Spouse 84A

Regular Rate Taxpayer/Filer Spouse 84D

84 Net Income/(Loss) per Books 85 Add: Other Taxable Income/Non-deductible Expenses

84B

84C

85A 86 Total (Sum of Items 84A & 85A/ 84B & 85B/ 84C & 85C/ 84D & 85D) 87 Less: Total Non-taxable Income and Income Subjected to Final Tax 87A 88 Special Deductions (e.g. direct labor, training, etc.) 88A 89 Total (Sum of Items 87A & 88A/ 87B & 88B/ 87C & 88C/ 87D & 88D) 90 Net Income (Item 86A less 89A/ 86B less 89B/ 86C less 89C/ 86D less 89D) (from Item 64C & 64D/ 64E & 64F) Part VII
Legal Basis (Special Law-R.A.

85B 86B

85C 86C

85D 86D

86A

87B

87C

87D

88B 89B 90B

88C 89C 90C

88D 89D 90D

89A 90A

Details of Income Tax Incentives/Exemptions (attach additional sheet/s, if necessary)

No./Particular Sec. in the Tax Code of 1997, as amended

Certificate of Registration/BIR Ruling/MOA/Others (A) 91 92 93 94 95 96 97

(B)

Effectivity Date of Incentive Exemption (state exact dates) From (MM/DD/YYYY) To (MM/DD/YYYY) (C) (D)

Nature and Extent of Incentive/Exemption (E)

Amount of Income Tax Payable under Regular Rate Taxpayer/Filer (F) Spouse (G)

Amount of Actual Income Tax Paid Taxpayer/Filer (H) Spouse (I)

Amount of Tax Relief/Savings Taxpayer/Filer ( J ) = (F less H) Spouse ( K ) = (G less I)

98 Total (Sum of Items 91J to 97J/ 91K to 97K) (to Item 45)

98

BIR Form No. 1701 - page 5

Part VIII For Eatate and Trust (Engaged in Trade and Business) Name 99A 100A 101A Payments to Heirs/Beneficiaries (attach additional sheet/s, if necessary) Taxpayer Identification Number (TIN) 99B 100B 101B 102 Amount Tax Withheld

99 100 101 102 Total Payment to Heirs/Beneficiaries (Sum of Items 115B, 116B & 117B)

99C 100C 101C

I declare, under the penalties of perjury, that this annual 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 the regulations issued under authority thereof.

103

SHERYL WONG Signature over Printed Name of Taxpayer/Authorized Representative (attach authorization) /Accredited Tax Agent (ATA) 105 Place of Issue

Position and TIN of Authorized Representative/ATA

Tax Agent Accreditation No./Atty's Roll No. (if applicable) Issue Date Expiry Date 106 Date of Issue (MM/DD/YYYY) 107 Amount

104 Community Tax Certificate Number Part IX

Gross Income/Receipts Subjected to Final W/holding Tax on Income Actual Amount
108A

Supplemental Information (attach additional sheet/s, if necessary) TAXPAYER/FILER Final Tax Withheld/paid Exempt
108B

Actual Amount
108E

SPOUSE Final Tax Withheld/Paid Actual Amount/Fair Market Value/Net Capital Gains
109C 110C 111C 112C 113C 108F

Exempt Final Tax Withheld/Paid

109D 110D 111D 112D 113D

108 Interests

108C

108D TAXPAYER/FILER Actual Amount/Fair Market Final Tax Withheld/Paid Value/Net Capital Gains

SPOUSE

109 Royalties 110 Dividends 111 Prizes and Winnings 112 Fringe Benefits 113 Compensation Subject to 15% Preferential Rate 114 Sale/Exchange of Real Properties
Description of Property (e.g., land, building, improvement)
114A 114H 114B 114I

109A 110A 111A 112A 113A

109B 110B 111B 112B 113B

OCT/TCT/CCT/Tax Declaration Number

114C 114J

Certificate Authorizing Registration (CAR) Number

114D 114K

114E 114L

114F 114M

114G 114N

115 Sale/Exchange of Shares of Stocks

Kind of Stocks*
115A 115J 115B 115K

Stock Certificate Series Number

115C 115L

Certificate Authorizing Registration (CAR) Number

115D 115M

Number of Shares
115E 115N

Date of Issue (MM/DD/YYYY)

115F 115O

115G 115P

115H 115Q

115I 115R

[*e.g., preferred (PS), common (CS)]

116 Other Income Subject to Final Tax Under Sec. 57(A) of the Tax Code, as amended (specify)
116A 116B

116C 117A

116D

116E 117B

117 Total Final Tax Withheld/Paid (Sum of Items 108b to 113B, 114E, 114L, 115G, 115P & 116C/ 108E, 109D to 113D, 114G, 114N, 115I, 115R & 116E)
Gross Income/Receipts Exempt from Income Tax

Actual Amount/Fair Market Value

118A 119A 120A

Actual Amount/Fair Market Value

118B 119B 120B

118 Proceeds of Life Insurance Policy 119 Return of Premium 120 Retirement Benefits, Pensions, Gratuities, etc. 121 Personal/Real Properties Received thru Gifts, Bequests, and Devises
Description of Property (e.g., cash, land, building, improvement)
121A 121B

Mode of Transfer (e.g., inheritance, donation)

121C

Certificate Authorizing Registration (CAR) Number

121D

121E

122 Other Exempt Income/Receipts Under Sec. 32 (B) of the Tax Code, as amended (specify)

122A

122B 123A

122C 123B

123 Total Income/Receipts Exempt from Income Tax (Sum of Items 63A to 65A, 66D & 67B/ 63B to 65B, 66E & 67C)