t.

+\ Republic ot the Fhllippines

BlFt { rffi I Department st Finance
For BC : \ lI / Bureau sf lnterrlal Flevenue
Uss Orii-Y ,t€m:

BiR Fom lio.

a55rQ Quarterly Percentase Tax Return Ir

IErERS aLACK
:nteralt requires infarmation in CAPTTAL irik. Mark applicable boxes u4th ar
risrnEt
T II
iafiuary 2018(ENCS) "X". Two copies MUST be fiiled with the BIR and one held hy the Taxpayer. sj
Fage t

'! For the CalenOar Fiscal 3 Quarter 4 AmendedReturc? 5 No.cfsheet:s

V6., F:1dad ' ]st ',r :nO . ., 3rd . . 4th Yes No Arta.i)ed
l ll'l'i'r'"rvw1 tvt,
Pa rt I Baekgro'*t"ld .1_*.t*.matlsc1
fi Taxpayer lndentifrcation llumber (TiN) 2S6 103 ,902 000 / RDO Code

ff Taxpayer's Name (Last Neme, First Name, Middle Narne for lndividual OR fiegistered Name far Non-lndividual)
,SHAI- Fi ZIS t--lAlv BASi-t I R
"
5o Registered Acidress (lndicate complete address. if branch, jndicate the braneh add,ess. lf the registered address is diiferent from ihe cuffent address, go to 9Aztp coue
rhe RDO io update registered address using BIR Form Nc. 1905)
136 M SANTOS ST BRGY 2'J PASAY CITY, NCR TOURTi_I LIS-IRiCT PHILIPPINES
{*oc
'1CI Contact Number ilanrJline/Cellnhane No.)
niea*:red
,$.re you arraiiing tax relief ilnder I 1?A
:
'' Yes '' "Nc
'Ji ,
IA speciel Law/lnternational itves' specJ! '
ru*fiL*tyr
,r't (fniy for" indlvicluai taxpayers whose $aleslreceipts are sutrjed to Percentage Tax under section J 1 6 of the Tax Code, as amended:
U*rat income tax rates are you ava,ling? {choose one)
fl-a be fllled out oniy cn the initia! ,.ri. Graduated income lax !"ate on net taxable
quartei af th€ taaable year) inftlffie SY. inccn]* lax rate cln gro33 saleslreceiFrslfiiheis

Fart ll - Total Tax Payable

'14 Toial Tax Eue sfi5 {30

t-ess: Tax CredillPayrnent (a!ia.ih piocf)

15 Creditable Fercentage Tax Withhetd per BIR Form No. 2307 flnn
V.VU

16 Tax Paid in Return Previousiy Filed" if this is an Arnended Reiurn tt.oo

17 tlther Tax CreditlPayme"tt
- - 0.00
{spec.ity)

f I Total Tax CreditslPayments {Sum of items 15 tc 17) -- 0.00

'tS Tax Stitl Payablel(Overpayment) (liem 14less ltern 18i ?.sos.oo
A"dci: Penalties

28 Surcherge : C'00
21 lnterest 000
S'j a^s^r^miq6 !'"v-
ea uu'ril-/'w u00
'
23 Tetal Penaities {Suffi flf lte.ns ?0 to 22) 0.00
24 TOTI\I- AMOUNT PAYABLE{Overpayrnent} (sum oi ttems 1e and 23) 7.905.00

lr overpayment. nrark one box only. To be refunded To be issu€d a Tax Credit Cedif,cate

attach authorization letter)

cr !ndividual: 0t llon-!ndivrdual

Slgnature over Printed Name of Taxpayer/Authorized RepresentativelTax Agent Signature over Printed Name of Piesiden$r'ice Presidenu
( I ndicate T itle/Desifi n atia n a n d 1-l !'l ) AuthariT:ed Offiaer or Reoresentative/Tax Aoert {lniiimle Titl€,'Desiaration anC i !i,!.
Tax,Agent Acc{editatron fllo.i uate ol lssue Date of Expiry
t{t/tiJ! n1n/Y\/]/1/),
a.ttornev's Roll No. llf aoolicaiiel IMA4/DDNYYY}
Part lll - Details of Payrnent
ParticulaE orawee Bank A$encv Number BatC {MM/DO/YYYY} Amcunt
25 aash/Eank Debii lr{emc

26 check

27 TaxDeblrMen:
?8 Others f srecifr' belog

Machine ValiciationlRevenue Ofticial Receipt iROR) Detaiis Starnp a{ Recetuing Ofiice/AAB and Date cf Receipt
(ff not filed with an Authoized Agent BanK) {RO's Signatu re,tsa n k Telle/ s I nitia I)

*NOTE: Please read the BIR Daia Privacv Policv found in the BIR website (www.bir.qov.oh