Annex A

For Taxpayer

SWORN STATEMENT

I, _____________(name)_____ _________, ____(owner/position)_____ of

_______(Registered Name of Taxpayer Issued LN) __ with business address at
____________________________________________ and TIN ____________ after having been
duly sworn to in accordance with law, hereby depose and state that:

1. The figures / discrepancy reflected in Letter Notice (LN) No. __________________

dated ________________ issued in favor of _________________________________
is not an accurate statement of our sales / purchases and VAT liabilities for taxable
year _______.

2. The figures shown hereunder represent our actual sales / purchases to / from the
following customers / suppliers as recorded in the books of accounts and as declared
in the returns filed for taxable year ________.

Vatable Sales / Purchases (Goods &

Name of Customers / Suppliers Services) Net of VAT
Q1 Q2 Q3 Q4 Total

3. We have declared the output / input taxes (VAT) on the aforesaid sales / purchases
amounting to P________________ and that the original VTA invoices / receipts are
part of our accounting records.

4. We hereby attest to the veracity of the Schedules of Sales / Purchases (Annexes

________) and authenticity of the supporting documents, e.g. invoices, receipts, etc.
presented to the Bureau of Internal Revenue (BIR) for purposes of substantiating the
sales / purchases figures reflected in the above Schedules and declared as such in the
returns required to be filed by the BIR for taxable year _____.

_________________________________
Registered Name of Taxpayer Issued LN

_________________________________
(Signature Over Printed Name)
President/Chief Finance Officer/Equivalent

SUBCRIBED AND SWORN to before me, this _____ day of ______________, 200__, at
______________, affiant exhibiting to me his/her Community Tax Certificate, as follows:

Name CTC Number Date of Issue Place of Issue

NOTARY PUBLIC
Doc. No. ________
Page No. ________
Book No. _______
Series of 200_____