(To be filled up by the BIR)

DLN:
Republika ng Pilipinas Kagawaran ng Pananalapi

Taxpayer PSOC:

PSIC:

Spouse PSOC:
BIR Form No.

PSIC:

Kawanihan ng Rentas Internas For Self-Employed Individuals, Estates, and Trusts (Including those w/ both Business & Compensation Income)
Fill in all applicable spaces. Mark all appropriate boxes with an X.

Quarterly Income Tax Return

X
3 Amended 3rd Return Information TIN Yes

1701Q
July 2008 (ENCS)

1 Part I

For the Year (YYYY)

2012
Taxpayer/Filer

2 Quarter

1st 2nd Background 6 RDO Code

X
Spouse

4 No. of sheet/s No attached

5 9 11

TIN

914

856

855

087

7 10 12

Taxpayer's Name(Last Name, First Name, Middle Name)(Estates & Trusts)

Spouse's Name (Last Name, First Name, Middle Name)(If applicable)

91 4

856

847

8 RDO Code

ACASO, ARNOLD P.
Registered Address

ACASO, ANTONIA C.
Registered Address

Phase 2, Public Market, Calbayog City

13 Date of Birth (MM/DD/YYYY) 14 Zip Code 15 Telephone Number

Phase 1, Public Market, Calbayog CIty

16 Date of Birth (MM/DD/YYYY) 17 Zip Code 18 Telephone Number

19

Line of Business/Occupation

20
ATC

II 01 II 01 II 01

Compensation Business Mixed Income

21 Line of Business/Occupation

22
ATC

II 01 II 01 II 01

Compensation Business Mixed Income

Native products/lessor
23 Method of Deduction

Native products
24 Method of Deduction X Itemized Deduction Yes Computation of Tax Taxpayer/Filer No

Itemized Deduction

40% Optional Standard Deduction

40% Optional Standard Deduction

25 Are you availing of tax relief under Special Law or International Tax Treaty? Part II Declaration This Quarter 26 Sales/Revenues/Receipts/Fees 27 Add: Amount Received by a Partner from General
Professional Partnership (except loans)

If yes, specify Spouse 26B 27B

26A 27A 28A 29A 30A 31A 32A 33A 34A 35A 36A 37A 38A 38C 38E 38G 38I 38K 38M 39A 40A 40C 40E 40G 41A

43,026.50 43,026.50 38,938.98 4,087.52 102,500.00 106,587.52 96,994.64 9,592.88 28,768.13 38,361.01 3,754.15 2,376.88

42,095.00 42,095.00 29,466.50 12,628.50 12,628.50 7,577.10 5,051.40 16,286.45 21,337.85 1,633.79 1,128.65

28 29 30 31 32 33 34 35 36 37 38

Total Less: Cost of Sales/Services Gross Income from Operation Add: Other Income Total Gross Income Less: Deductions Taxable Income This Quarter Add: Taxable Income Previous Quarter/s Taxable Income to Date Tax Due Less: Tax Credits/Payments
38A/B Prior Years' Excess Credits 38C/D Tax Payment/s for the Previous Quarter/s 38E/F Creditable Tax Withheld for the Previous Quarter/s 38G/H Creditable Tax Withheld Per BIR Form No. 2307

28B 29B 30B 31B 32B 33B 34B 35B 36B 37B 38B 38D 38F 38H 38J 38L

for this Quarter

38I/J Tax Paid in Return Previously Filed,

if this is an Amended Return 38K/L Other Payment/s Made (please attach proof of payment-BIR Form No. 0605)
38M/N Total Tax Credits/Payments (Sum of 38A,C,E,

2,376.88 1,288.13

38N 39B 40B 40D 40F 40H 41B

1,128.65 519.15

G,I & K/ 38B,D,F,H,J,& L)

39 40

Tax Payable/(Overpayment) (37A less 38M & 37B less 38N) Add: Penalties Surcharge Interest Compromise Total Penalties (Sum of Items 40A,C,E/40B,D,F) Total Amount Payable/ (Overpayment)(39A+40G/39B+40H) Aggregate Amount Payable/(Overpayment) ( Sum of Items 41A & 41B)

41

1,377.27
41C

505.14 1,882.41

I declare under penalties of perjury, that this return has been made in good faith, verified by me, and to the best of my knowledge and belief, is true and correct, pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof.

42

ACASO, ARNOLD P.
Taxpayer/Authorized Representative/Accredited Tax Agent Signature Over Printed Name Title/Position of Signatory TIN of Signatory

Tax Agent Acc. No./Atty's Roll No. (if applicable) Part III Drawee Bank/ Particulars 43 Cash/Bank Debit Memo 44 Check 45 Tax Debit Memo 46 Others
46A 46B 46C

Date of Issuance

Date of Expiry Stamp of Receiving Office/

D e t a i l s of P a y m e n t Date Number
43B 44B 45A 43C 44C 45B

Agency
43A 44A

MM DD

YYYY
43D 44D 45C 46D

Amount

AAB and Date of Receipt (RO's Signature/ Bank Teller's Initial

Machine Validation/Revenue Official Receipt Details (If not filed with the bank)

Q
0 8 7

Telephone Number

mpensation

ed Income

f Receiving Office/

d Date of Receipt

O's Signature/ k Teller's Initial