(Annex “A”)

CERTIFICATION

This is to certify that (Name of Security Agency) has religiously complied with its
obligation as a withholding agent pursuant to the provisions of Sections 79, 80 and 81 of
the Tax Code and its implementing regulations. As a designated withholding agent, it has
withheld and remitted the correct tax on wages paid to the security guards assigned for
duty with (Name of Client) , with the information thereon detailed as follows:

Name of Guard TIN Employment Dates Amt. of Salaries Tax Withheld

1. to
2. to
3. to
4. to
5. to

It is further certified that the amount of salaries and the amount of tax withheld
mentioned above corresponds to the amount reported in the annual Apha List required to
be submitted by the herein withholding agent.

This certification is issued to (Name of Client) in compliance with

the requirements set forth under RMC No. __________.

Sgd. (Responsible Officer)

Security Agency

SUBSCRIBED AND SWORN TO before me this ____ day of ________, 200__

in _______________, affiant exhibiting to me his/her Community Tax Certificate No.
_____________ issued on _______________ at _______________.

Notary Public

Page No. _______

Doc No. _______
Book No. _______
Series of ________