1 For the Period

From (MM/DD/YY) To (MM/DD/YY)

Part I Income Recipient/Payee Information Withholding Agent/Payor Information
2 TIN 3 TIN
4 Payee's Name (For Non-Individuals ) 5 Payor's Name (For Non- Individuals)
6 Payee's Name (Last Name, First Name, Middle Name) For Individuals 7 Payor's Name (Last Name, First Name, Middle Name) For Individuals
8 e!istered "ddress e!istered "ddress
8A !ip
#ode #ode
1" Forei!n "ddress 1"A $i% #ode
Part II #etail$ of Income Payment and %a& Withheld
'at(re of Income Payment A % ) Amo(nt of Payment %a& Withheld

*A% Withholding on P(rcha$e of +er,ice$ - &'()** (&)+*
.o,ernment Withholding Agent
%otal (&)+*
,e de-lare, under the %enalties o. %er/ury, that this -erti.i-ate has 0een made in !ood .aith, veri.ied 0y us, and to the 0est o. our 1no2led!e and 0elie., is true and
-orre-t %ursuant to the %rovisions o. the National Internal evenue #ode, as amended, and the re!ulations issued under authority thereo.)
11 A/I)0 *1 2A'.AR3'
Payor/Payor's "uthori3ed e%resentative Date 4i!ned
4i!nature 5ver Printed Name
#5NF5M67
444 Date 4i!ned
Payee/Payee's "uthori3ed e%resentative
4i!nature 5ver Printed Name
%o 5e accompli$hed for *al(e-Added %a&/Percentage %a& Withholding 6$(5$tit(ted filing7
I de-lare, under the %enalties o. %er/ury, that the in.ormation I de-lare under the %enalties o. %er/ury that I am 8uali.ied under su0stituted .ilin! o. Per-enta!e
herein stated are re%orted under 9I Form No) :'** 2hi-h Ta;/<alue "dded Ta; eturns (9I Form +&&:M/+&&*M/=), sin-e I have only one %ayor .rom
have 0een .iled 2ith the 9ureau o. Internal evenue) 2hom I earn my in-ome> that, in a--ordan-e 2ith :?-+**@, I have availed o. the 5%tional
e!istration under the @A Final Per-enta!e Ta; ,thholdin!/:*A Final <"T ,ithholdin! in lieu
o. the @A Per-enta!e Ta;/:*A <"T in order to 0e entitled to the %rivile!es a--orded 0y the
4u0stituted Per-enta!e Ta; eturn/4u0stituted <"T eturn 4ystem %res-ri0ed in the a.oresaid
e!ulations> that, this De-laration is su..i-ient authority o. the 2ithholdin! a!ent to 2ithhold @A
Final Per-enta!e Ta;/:*A Final <"T .rom my sale o. !oods and/or servi-es)
13 14
Payor/Payor's "uthori3ed e%resentative Payee/Payee's "uthori3ed e%resentative
4i!nature 5ver Printed Name 4i!nature 5ver Printed Name
Le!end7
N"6T9 B Non-resident "lien 6n!a!ed in Trade or 9usiness NF# B Non- resident Forei!n #or%oration F#DC B Forei!n #urren-y De%osit Cnit
N"N6T9 B Non-resident "lien Not 6n!a!ed in Trade or 9usiness 59C B 5..shore 9an1in! Cnit P6$" B Phili%%ine 6;%ort $one "uthority
49M" B 4u0i- 9ay Metro%olitan "uthority #D" B #lar1 Develo%ment "uthority
A $i%
1"8 I# No) (For "lien In-ome e-i%ient 5nly)
0 1 0 7 1 4
449 876 374 416
#5T6L#5, IN#) M"DIL"L" #6NT"L 6L6M6NT"Y 4#E55L
9 4 0 1
W I 320
9I Form No)
+@*'
Mar-h +**@ (6N#4)
M"NC9C"N, M"T"L"M, #5T"9"T5 M"DIL"L", #5T"9"T5
#erti.i-ate o. Final Ta;
,ithheld "t 4our-e
Republika ng Pilipinas
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas
0 7 3 1 1 4
+)90#:/0+ 3; A/P9A':20RI) %A< )3#0+
'at(re of Income Payment
A % )
I'# )3RP
Income %a&
;ringe 8enefit
1 "lien individual em%loyed 0y 59C's, Forei!n Petroleum 4ervi-e #ontra-tors, F 4u0-ontra-tors,
,F @+* F 0y e!ional or "rea Eead8uarters F e!ional 5%eratin! Eead8uarters o. Multinational #o),
in-ludin! any o. its Fili%ino em%loyees o--u%yin! the same %osition
2 Payment o. .rin!e 0ene.its to Non-esident "lien Not 6n!a!ed in Trade or 9usiness (N"6T9) ,F @@*
3 6m%loyees other than ran1 and .ile 0ased on the !rossed-u% monetary value ,F @'*
Intere$t/=ield from 8an> #epo$it$/#epo$it +(5$tit(te$/.o,ernment +ec(ritie$
4 4avin! De%osit ,I :': ,# :':
5 Time De%osit ,I :': ,# :':
6 Government 4e-urities ,I :'+ ,# :'+
7 De%osit 4u0stitutes/5thers ,I :'@ ,# :'@
8 Forei!n #urren-y De%osits ,I :H* ,# :H*
Preterminated Lon! Term De%osit/Investment ,# ??*
Less than three (@) years ,I ??*
Three (@) years to less than .our (?) years ,I ??:
Four (?) years to less than .ive (&) years ,I ??+
All 3ther$
1" Interest on .orei!n loans %aya0le to NF#s ,# :(*
11 Interest and other in-ome %ayments on .orei!n -urren-y transa-tion /loans %aya0le to 59Cs ,# :I*
12 Interest and other in-ome %ayments on .orei!n -urren-y transa-tion /loans %aya0le to F#DCs ,# :I:
13 #ash dividend %ayment 0y domesti- -or%oration to -iti3en F resident aliens/NF#'s ,I +*+ ,# +:+
14 Pro%erty dividend %ayment 0y domesti- -or%oration to -iti3ens F resident aliens/NF#'s ,I +*@ ,# +:@
15 #ash dividend %ayment 0y domesti- -or%) to NF#s 2hose -ountries allo2ed ta; deemed %aid -redit ,# +++
16 Pro%erty dividend %ayment 0y domesti- -or%) to NF#s 2hose -ountries allo2ed ta; deemed %aid -redit ,# ++@
17 5n other %ayments to NF# ,# +@*
18 #ash dividend %ayment 0y domesti- -or%oration to N"6T9 ,I ++?
1 Pro%erty dividend %ayment 0y domesti- -or%oration to N"6T9 ,I ++&
2" 4hare o. a N"6T9 in the distri0uta0le net in-ome a.ter ta; o. a %artnershi% (e;-e%t General Pro.essional
,I ++' Partnershi%) o. 2hi-h he is a %artner, or share in the net in-ome a.ter ta; o. an asso-iation,
a /oint a--ount or a /oint venture ta;a0le as a -or%), o. 2hi-h he is a mem0er or a -o-venturer
21 Distri0utive share o. individual %artners in a ta;a0le %artnershi%, asso-iation,
,I +?*
a /oint a--ount or a /oint venture or -onsortium
22 5ther royalty %ayments to -iti3ens, resident aliens and N"6T9
,I +&* ,# +&*
(other than ,I@(* and ,I @?:) /domesti- and resident .orei!n -or%oration
23 5n %ri3es e;-eedin! P:*,*** F other 2innin!s %aid to individuals ,I +'*
24 9ran-h %ro.it remittan-es 0y all -or%orations e;-e%t P6$"/49M"/#D" re!istered ,# +(*
25 5n the !ross rentals, lease and -harter .ees derived 0y non-resident o2ner or lessor o. .orei!n vessels ,# +I*
26 5n the !ross rentals, lease and -harter .ees derived 0y non-resident lessor o. air-ra.t,
,# @**
ma-hineries and other e8ui%ment
27 Payment to 5il 6;%loration 4ervi-e #ontra-tors/4u0-#ontra-tors ,I @:* ,# @:*
28 Payment to Fili%inos or "lien individuals em%loyed 0y Forei!n Petroleum 4ervi-e #ontra-tors/
,I @+* 4u0-ontra-tors, 5..shore 9an1in! Cnits and e!ional or "rea Eead8uarters and e!ional 5%eratin!
Eead8uarters o. Multinational #om%anies o--u%yin! e;e-utive/mana!erial and te-hni-al %ositions
2 Payments to Non-esident "lien Not 6n!a!ed in Trade or 9usiness (N"6T9) e;-e%t on sale o. shares
,I @@*
in domesti- -or%oration and real %ro%erty
3" Payments to non-resident individual/.orei!n -or%orate -inemato!ra%hi- .ilm o2ners, lessors or distri0utors ,I @?* ,# @?*
31 oyalties %aid to N"6T9 on -inemato!ra%hi- .ilms and similar 2or1s ,I @?:
32 Final Ta; on interest or other %ayments u%on ta;-.ree -ovenant 0onds, mort!a!es, deeds o. trust or
,I @&*
other o0li!ations under 4e-) &H# o. the National Internal evenue #ode o. :IIH
33 oyalties %aid to -iti3ens, resident aliens F non-resident alien en!a!ed in trade or 0usiness (N"6T9)
,I @(*
on 0oo1s, other literary 2or1s F musi-al -om%ositions
34 Payments to ta;%ayer en/oyin! Pre.erential Ta; ates/Ta; Treaty ates ,# @I*
35 In.ormer's -ash re2ard to individuals//uridi-al %erson ,I ?:* ,# ?:*
36 Final #a%ital Gains Ta; on 4ale/6;-han!e or 5ther Dis%osition o. eal Pro%erty ,I ?&* ,# ?&*
;or 8($ine$$ %a&
37 <"T ,ithholdin! on Pur-hase o. Goods (2ith 2aiver o. %rivile!e to -laim in%ut ta; -redits) ,< *:? ,< *:?
38 <"T ,ithholdin! on Pur-hase o. 4ervi-es (2ith 2aiver o. %rivile!e to -laim in%ut ta; -redits) ,< *+? ,< *+?
3 Person e;em%t .rom <"T under 4e-) :*I (3) (2ith 2aiver o. %rivile!e to -laim in%ut ta; -redits) ,9 *(? ,9 *(?
4" ,9 :I:
41 Ta; on ,innin!s and Pri3es on horse ra-es/o2ners o. 2innin! ra-ehorses (4e-) :+') - Gov't) ,ithholdin! "!ent (:*A) ,9 :I+
42 ,9 :I@
43 Ta; on ,innin!s and Pri3es on horse ra-es/o2ners o. 2innin! ra-ehorses (4e-) :+' ) - Private ,ithholdin! "!ent (:*A) ,9 :I?
44 <"T ,ithholdin! on Non-residents - Gov't) ,ithholdin! "!ent ,< *?*
45 <"T ,ithholdin! on Non-residents - Private ,ithholdin! "!ent ,< *&*
Ta; on ,innin!s and Pri3es (4e-) :+') (double/forecast/quinella/trifecta 0ets) - Gov't) ,ithholdin! "!ent (?A)
Ta; on ,innin!s and Pri3es (4e-) :+' ) (double/forecast/quinella/trifecta 0ets) - Private ,ithholdin! "!ent (?A)