(To be filled up by the BIR)

DLN: PSIC:

Fill in all applicable spaces !a"# all app"op"iate bo$es %ith an &'(
1 Fo" the Calenda" Fiscal Fo" the )onth 5 Nu)be" of sheets attached
2 *ea" ended
Part I B a c k g r o u n d I n f o r m a t i o n
6 TIN 8 Line of Business+
,ccupation
9
Ta$paye"-s Na)e (Fo" Indi.idual)Last Na)e/ Fi"st Na)e/ !iddle Na)e+(Fo" Non0indi.idual) Re1iste"ed Na)e
11 Re1iste"ed 2dd"ess 12 3ip Code
13 2"e you a.ailin1 of ta$ "elief unde" Special La%
o" Inte"national Ta$ T"eaty4
*es No If yes/ specify
Part II C o m p u t a t i o n o f T a x
Ta$able T"ansaction+ 2 T C Ta$able 2)ount Ta$ Rate Ta$ Due
Indust"y Classification
14A 14B 14C 14D 14
15A 15B 15C 15D 15
16A 16B 16C 16D 16
1!A 1!B 1!C 1!D 1!
18A 18B 18C 18D 18
19 Total Ta$ Due 19
2" Less: Ta$ C"edits+Pay)ents
2"A C"editable Pe"centa1e Ta$ 5ithheld Pe" BIR Fo") No 6789 (See Schedule :) 2"A
2"B Ta$ Paid in Retu"n P"e.iously Filed/ if this is an 2)ended Retu"n 2"B
21 Total Ta$ C"edits+Pay)ents (Su) of Ite)s 682 ; 68B) 21
22 Ta$ Payable (,.e"pay)ent) (Ite) :< less Ite) 6:) 22
23 2dd: Penalties Su"cha"1e Inte"est Co)p"o)ise
23A 23B 23C 23D
24 Total 2)ount Payable+(,.e"pay)ent) (Su) of Ite)s 66 and 67D) 24
If o.e"pay)ent/ )a"# one bo$ only: To be Refunded To be issued a Ta$ C"edit Ce"tificate
I decla"e/ unde" the penalties of pe"=u"y/ that this "etu"n has been )ade in 1ood faith/ .e"ified by )e/ and to the best of )y #no%led1e/ and belief/
is t"ue and co""ect/ pu"suant to the p"o.isions of the National Inte"nal Re.enue Code/ as a)ended/ and the "e1ulations issued unde" autho"ity the"eof
25 26
P"esident+>ice P"esident+P"incipal ,ffice"+2cc"edited Ta$ 21ent+ T"easu"e"+2ssistant T"easu"e"
2utho"i?ed Rep"esentati.e+Ta$paye" (Si1natu"e ,.e" P"inted Na)e)
(Si1natu"e ,.e" P"inted Na)e)
Title+Position of Si1nato"y TIN of Si1nato"y Title+Position of Si1nato"y
Ta$ 21ent 2cc No+2tty-s Roll No(if applicable) Date of Issuance Date of @$pi"y TIN of Si1nato"y
Part III D#tai$% of Pa&m#nt
Dra'## Bank( Dat# Sta)p of
3 4 2)ended Retu"n
! RD, Code
1" Telephone Nu)be"
6AA:!
Septe)be" 688A (@NCS)
!onthly Pe"centa1e
Ta$ Retu"n
BIR Fo") No
Republi#a n1 Pilipinas
Ba1a%a"an n1 Pananalapi
Ba%anihan n1 Rentas Inte"nas
*es No (!!+****) (!!+****)

Particu$ar% Ag#nc& )um*#r ++ DD ,,,, Amount Recei.in1 ,ffice+22B
2!B 2!C 2!D and Date of Receipt
Debit !e)o (R,-s Si1natu"e+
28B 28C 28D
Ban# Telle"-s Initial)
29A 29B 29C
!e)o
3"B 3"C 3"D
!achine >alidation+Re.enue ,fficial Receipt Details (If not filed %ith an 2utho"i?ed 21ent Ban#)
BIR F,R! 6AA:! (@NCS)0P2C@ 6
-c.#du$# 1 Tax /it..#$d C$aim#d a% Tax Cr#dit
P#riod Co0#r#d
)am# of /it..o$ding Ag#nt Incom# Pa&m#nt% Tax /it..#$d App$i#d
Tota$ 1To It#m 2"A2
A3P4A)5+6IC TA7 C8D 1ATC2
ATC P#rc#ntag# Tax 8n9 Tax 6at# ATC P#rc#ntag# Tax 8n9 Tax 6at#
PT 8:8 Pe"sons e$e)pt f"o) >2T unde" Sec :8<. (Sec ::D) 7E PT :87 7) ,n "oyalties/ "entals of p"ope"ty/ "eal o" pe"sonal/ p"ofits 9E
PT 8F8 Do)estic ca""ie"s and #eepe"s of 1a"a1es 7E f"o) e$chan1e and all othe" 1"oss inco)e
PT 8F: Inte"national Ca""ie"s 7E
PT :8F F) ,n net t"adin1 1ains %ithin the ta$able yea" on fo"ei1n cu""ency/
PT 8D8 F"anchises on 1as and %ate" utilities 6E
debt secu"ities/ de"i.ati.es/ and othe" financial inst"u)ents
9E
PT 898 F"anchises on "adio+T> b"oadcastin1 co)panies %hose Ta$ on ,the" Non0Ban# Financial Inte")edia"ies not pe"fo")in1 Guasi0ban#in1 functions
annual 1"oss "eceipts do not e$ceed P :8 ! 7E :) ,n inte"est/ co))issions and discounts f"o) lendin1 acti.ities
Ta$ on ban#s and non0ban# financial inte")edia"ies pe"fo")in1 Guasi as %ell as inco)e f"o) financial leasin1/ on the basis of "e)ainin1
ban#in1 functions )atu"ities of inst"u)ents f"o) %hich such "eceipts a"e de"i.ed
:) ,n inte"est/ co))issions and discounts f"o) lendin1 PT ::7 !atu"ity pe"iod is fi.e (A) yea"s o" less AE
acti.ities as %ell as inco)e f"o) financial leasin1/ on
PT ::F
!atu"ity pe"iod is )o"e than fi.e (A) yea"s :E
the basis of "e)ainin1 )atu"ities of inst"u)ents f"o) PT ::A 6)
F"o) all othe" ite)s t"eated as 1"oss inco)e unde" the code
AE
%hich such "eceipts a"e de"i.ed PT :68 Life Insu"ance p"e)iu) AE
PT :8A !atu"ity pe"iod is fi.e (A) yea"s o" less AE 21ents of Fo"ei1n Insu"ance Co)panies
PT :8: !atu"ity pe"iod is )o"e than fi.e (A) yea"s :E PT :78 a) Insu"ance 21ents :8E
PT :86 6) ,n di.idends and eGuity sha"es and net inco)e of PT :76 b) ,%ne"s of p"ope"ty obtainin1 insu"ance di"ectly
subsidia"ies 8E %ith fo"ei1n insu"ance co)panies AE
BI6 :orm )o; 2551+ P#rc#ntag# Tax 6#turn
<uid#$in#% and In%truction%
2! Cash+Ban# 2!A
28 Chec# 28A
29 Ta$ Debit
3" ,the"s 3"A
"Gross receipts" means all amounts received by the prime or principal contractor,
undiminished by any amount paid to any subcontractor under a subcontract arrangement.

Penalties
There shall be imposed and collected as part of the tax:
A surcharge of twenty five percent (!"# for each of the following violations:
$ailure to file any return and pay the amount of tax or installment due on or before the due
date%
&nless otherwise authori'ed by the (ommissioner, filing a return with a person or office
other than those with whom it is re)uired to be filed%
$ailure to pay the full or part of the amount of tax shown on the return, or the full amount of
tax due for which no return is re)uired to be filed on or before the due date%
$ailure to pay the deficiency tax within the time prescribed for its payment in the notice of
assessment.
A surcharge of fifty percent (!*"# of the tax or of the deficiency tax, in case any payment
has been made on the basis of such return before the discovery of the falsity or fraud, for
each of the following violations:
+illful neglect to file the return within the period prescribed by the (ode or by rules and
regulations% or
,n case a false or fraudulent return is willfully made.
,nterest at the rate of twenty percent (*"# per annum, or such higher rate as may be
prescribed by rules and regulations, on any unpaid amount of tax from the date
prescribed for the payment until the amount is fully paid.
(ompromise penalty.

Attachments Required
(ertificate of (reditable Tax +ithheld at -ource, if applicable%
.uly approved Tax .ebit /emo, if applicable%
$or amended return, proof of the payment and the return previously filed%
All returns filed by an authori'ed representative must attach authori'ation letter.

Note: All background information must be properly filled up.
All returns filed by an accredited tax representative on behalf of a taxpayer shall bear the
following information:
$or (0As and others (individual practitioners and members of G00s#%
a.1 Taxpayer ,dentification 2umber (T,2#% and
a. (ertificate of Accreditation 2umber, .ate of ,ssuance,
and .ate of 3xpiry.
$or members of the 0hilippine 4ar (individual practitioners, members of G00s#:
b.1 Taxpayer ,dentification 2umber (T,2#% and
b. Attorney5s 6oll 2umber or Accreditation 2umber, if any.
2os. 1, and 7 of this form refer to transaction period and not the date of filing this return.
The last 7 digits of the 18digit T,2 refers to the branch code.
T,2 9 Taxpayer ,dentification 2umber
32(-
!!1/
Who Shall File
This return shall be filed in triplicate by the following:
0ersons whose gross annual sales and:or receipts do not exceed 01,!**,*** and who
are not ;AT8registered persons.
.omestic carriers and <eepers of garages, except owners of bancas and owners of
animal8drawn two wheeled vehicle.
=perators of international air and shipping carriers doing business in the 0hilippines.
$ranchise grantees of gas or water utilities.
$ranchise grantees of radio and:or television broadcasting companies whose
gross annual receipts of the preceding year do not exceed Ten /illion 0esos
(01*,***,***.**# and did not opt to register as ;AT taxpayers.
4an<s, non8ban< financial intermediaries and finance companies.
>ife insurance companies.
Agents of foreign insurance companies.

When and Where to File
The return shall be filed not later than the *
th
day following the end of each month.
Any person retiring from a business sub?ect to percentage taxes shall notify the nearest
6evenue .istrict =ffice, file his return and pay the tax due thereon within twenty (*# days
after closing his business.
The return shall be filed with any Authori'ed Agent 4an< (AA4# within the territorial
?urisdiction of the 6evenue .istrict =ffice where the taxpayer is re)uired to
register:conducting business. ,n places where there are no AA4s, the return shall be
filed with the 6evenue (ollection =fficer or duly Authori'ed (ity or /unicipal Treasurer
within the 6evenue .istrict =ffice where the taxpayer is re)uired to register:conducting
business.
A taxpayer may, at his option, file a separate return for the head office and for each
branch or place of business or a consolidated return for the head office and all the
branches except in the case of large taxpayers where only one consolidated return is
re)uired.

When and Where to Pay
&pon filing this return, the total amount payable shall be paid to the Authori'ed
Agent 4an< (AA4# where the return is filed. ,n places where there are no AA4s,
payment shall be made directly to the 6evenue (ollection =fficer or duly Authori'ed (ity
or /unicipal Treasurer who shall issue a 6evenue =fficial 6eceipt 4,6 $orm 2o. !@#
therefor.
+here the return is filed with an AA4, taxpayer must accomplish and submit 4,68
prescribed deposit slip, which the ban< teller shall machine validate as evidence that
payment was received by the AA4. The AA4 receiving the tax return shall stamp mar< the
word A6eceivedB on the return and also machine validate the return as proof of filing the
return and payment of the tax by the taxpayer, respectively. The machine validation shall
reflect the date of payment, amount paid and transactions code, the name of the ban<,
branch code, teller5s code and teller5s initial. 4an< debit memo number and date should be
indicated in the return for taxpayers paying under the ban< debit system.

For lectronic Filing and Payment System !FPS" #a$payer
The deadline for electronically filing and paying the taxes due thereon shall be in
accordance with the provisions of existing applicable revenue issuances.

%asis of #a$
The tax is based on gross sales, receipts or earnings except on insurance
companies where the basis of tax is the total premium collected:paid.