TAX DECLARATION PSA

ANNEX “A-1”
INCOME PAYEE’S SWORN DECLARATION OF GROSS RECEIPTS/SALES

(For Self-Employed and/or Engaged in the Practice of Profession with Lone Income Payor)
JOHN RONNEL LABITAG SERVAZ FILIPINO

I, _________________________________________________, ___________________________, of legal age, single / married to
(Name) (Citizenship)
N/A
_____________________________________________________ 101 PUROK 3 ZONE 8
permanently residing at _________________________________
(Name of Spouse)
BARANGAY CUPANG, ANTIPOLO CITY, RIZAL 1870
____________________________________________________________________________________________________________ with
(Address)
511 – 526 – 910 - 000

Taxpayer Identification Number (TIN) _________________________________ _, after having been duly sworn in accordance with law
hereby depose and state:
1. ENUMERATOR
That I derived my ______________________ PHILIPPINE STATISTICS AUTHORITY - RIZAL
income only from ___________________________________________________
(business/professional) (Name of Lone Payor)
460-372-118-060
with Taxpayer Identification Number __ G/F BUDGETLANE SHOPPING
_________________ and business address at _____________________________________
___________________________________________________________________________________________________________;
CENTER, BRGY. SAN JOSE ANTIPOLO CITY
2. That for the current year ________,
2024 my gross receipts will not exceed Two Hundred Fifty Thousand Pesos (₱250,000.00) and that
I am registered as a non-VAT taxpayer; that whatever is the amount of income received, I will comply with the requirement to file my
Income Tax Return on the prescribed due date. For this purpose, I opt to avail of either one of the following:
 Graduated Income Tax Rates under Section 24(A)(2)(a) of the Tax Code, as amended, based on the taxable
income. With this selection, I acknowledge that I am subject to 0% income tax, thus, not subject to creditable
withholding tax; subject to percentage tax, if applicable, and will file the required percentage tax returns or subject
to withholding percentage tax, in case of government money payments.
 Eight Percent (8%) income tax rate under Section 24(A)(2)(b) of the Tax Code, as amended, based on gross
receipts/sales and other non-operating income - with this selection, I understand that this is in lieu of the graduated
income tax rates and the Percentage Tax under Section 116 of the Tax Code, as amended; thus, no withholding tax
shall be made;
3. That based on my selection above, if my gross sales/receipts and other non-operating income exceeds ₱250,000.00 but not over
₱3,000,000.00, my afore-stated lone income payor shall automatically withhold the prescribed rate of withholding tax:
a. In case of Graduated Income Tax Rates, I acknowledge that aside from income tax, I am subject to business tax
(Percentage Tax, if applicable) and creditable withholding of income in excess of P250,000.00, and business tax
withholding, if any, are applicable on the entire income payment; OR
b. In case of Eight Percent (8%) income tax rate, I acknowledge that I am only subject to income tax and thus, to the
creditable withholding income tax in excess of P250,000.00;
4. That I duly execute this SWORN DECLARATION in compliance with the requirement prescribed under Section 2.57.3 of
Revenue Regulations No. 11-2018 ;
5. That I declare, under the penalties of perjury, that this declaration has been made in good faith, and to the best of my knowledge
and belief to be true and correct.
IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of ____________, 20___ at ___________, Philippines
_____________________________________________
Signature over Printed Name of Individual Taxpayer
SUBSCRIBED AND SWORN to before me this _____ day of ____________, 20___ in _______________________________. Applicant exhibited
to me his/her ___________________________issued at _______________________ on _________________________.
(Government Issued ID and No.)
NOTARY PUBLIC
Doc. No.: __________
Page No.: __________
Book No.: __________

Series of ___________
Affix ₱ 30.00
Documentary
Stamp Tax
(To be filled-out by the withholding agent/lone payor)
Date Received: __________________ Received by:

(MM-DD-YYYY-00001)
_____________________________________________________________
Signature over Printed Name of the Withholding Agent/Payor or Authorized Officer
_____________________________________________________________
Designation/Position of Authorized Officer
_____________________________________________________________
Name of Withholding Agent/Lone Payor

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ANNEX “A-1”

INCOME PAYEE’S SWORN DECLARATION OF GROSS RECEIPTS/SALES

JOHN RONNEL LABITAG SERVAZ FILIPINO

511 – 526 – 910 - 000

hereby depose and state:

Book No.: __________

(To be filled-out by the withholding agent/lone payor)

Date Received: __________________ Received by:

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