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BIR FORM NO.

0804

Annex A
LIST OF ASSETS
Domestic and Foreign
(Name of Taxpayer)
January 09, 2014

Tax Identification Number (TIN): LA x MOA


Address: Tinago St., Cebu City

No. 201000047170 X
Tax Type: All Internal Revenue Tax
Taxable Year: 2012

A. Used in Business

Type

Real
Properties

Reference
(OCT/TCT/
CCT No. and/or
Tax Declaration
No.)

Location

Size/Area
(No. of
Units for
Machinery
and
Equipment)

Classification
(e.g.,
Residential,
Commercial,
Agricultural,
etc.)

Value (in Philippine


Peso)
(Cost, if acquired by
purchase; zonal value
or fair market value,
whichever is higher, if
by inheritance or
donation)

Land
Land and
Building
Others
Machinery
and
Equipment
(in detail)

Type/Nature
of Account

Account No.

Name/Address of Bank

Total Value
In Foreign
Currency

Cash on Hand
and in Bank

In Pesos

Total Collectible Amount


Type/Nature

Name & Address of Debtor

In Foreign
Currency

In Pesos

Receivables

Type/Nature of
Investment
Investments
in Stocks,
Bonds and
Other
Certificates
Type of
Motor
Vehicle
(Land, Air,
Water)

Name/Address
of Issuing
Company

No. of
Shares/
Units

Value per
Share/Unit

Total Value
In Foreign
Currency

In Pesos

Motor and
Engine
Number

Brand/Model

Plate No./Registration No.

Total Value

Type

Nature and Description

Physical Location

Value

Other

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Annex A
Business
Assets

B. Personal

Type

Real
Properties

Reference
(OCT/TCT/
CCT No. and/or
Tax Declaration
No.)

Location

Size/Area
(No. of
Units for
Machinery
and
Equipment)

Classification
(e.g.,
Residential,
Commercial,
Agricultural,
etc.)

Value (in Philippine


Peso)
(Cost, if acquired by
purchase; zonal value
or fair market value,
whichever is higher, if
by inheritance or
donation)

Land
Land and
Building
Others
(specify)

Type/Nature
of Account

Account No.

Name/Address of Bank

Total Value
In Foreign
Currency

Cash on Hand
and in Bank

In Pesos

Total Collectible Amount


Type/Nature

Name & Address of Debtor

In Foreign
Currency

In Pesos

Receivables

Type/Nature of
Investment

Name/Address
of Issuing
Company

No. of
Shares/
Units

Value per
Share/Unit

Total Value
In Foreign
Currency

In Pesos

Investments
in Stocks,
Bonds and
Other
Certificates

Type of
Motor
Vehicle
(Land, Air,
Water)

Other Assets

Motor and
Engine
Number

Brand/Model

Plate No./Registration No.

Total Value

Type

Nature and Description

Physical Location

Value

Jewelry

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Annex A
Furnitures

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