BRANCH
ETAX PAYMENT ENROLLMENT FORM
New Enrollment
Update (Please check the appropriate box for updates)
Change User ID
Change Registered Name
Change Password
Change Account Number
REGISTERED NAME / TAXPAYER'S NAME (Write in print)
Additional Account N
Individual
NGA/SUC RDO
Corporate
LGU
TAXPAYER'S ADDRESS (Write in print)
CONTACT NO.
NAME OF AUTHORIZED ENROLLEE ( Write in print)
Any one (1)
Any two (2)
1
2
3
4
E-MAIL ADDRESS (Write in print, case sensitive, the n
witten as "Ø" to differentiate from letter "O"
1
2
3
4
ACCOUNT NUMBER / S TO BE ENROLLED (Please attached separate sheet for other account nos.)
SAVINGS ACCOUNT
1
1
2
CURRENT
2
DEPOSITOR'S SIGNATURE
I / We hereby agree to the terms and conditions governing the E-Tax Payment Facility of LANDBANK
Signature Over Printed Name
Signature Over Printed Name
Signature Over Printed Name
For corporate taxpayer's a Board Resolution authorizing enrollment of the account(s), and designating authorized enrollees/password hol
Board of Directors / Trustees of the corporation to inform the bank of change in authorized enrollees.
FOR BRANCH USE
This is to certify that all details and information written above are true, accurate and complete per validation with other
required documents submitted by the client. Copies of documentary requirements are safekept in the branch for reference.
Signature Verified by:
Distribution:
Original copy AOSD
Processed by:
Copy 2: Branch / EO
Approved by:
Copy 3: Taxpayer
BRANCH
MENT FORM
Changed Authorized Enrollee
Additional Account Number
Additional Authorized Enrollee
Change email address
Change TIN
TIN (indicate the 12 digit number)
CONTACT NO.
E-TAXPAYER'S BRANCH CODE
(to be provided by BIR)
n print, case sensitive, the number zero should be
iate from letter "O"
USER ID (Write in print, 4 characters Alpha or numeric or combination)
1
2
3
4
CURRENT ACCOUNT
Signature Over Printed Name
ized enrollees/password holders shall be required. It is the responsibility of the
FOR AOSD ENROLLMENT
Enrolled by:
Checked by:
Approved by: