Republic of the Philippines
Department of Finance
BUREAU OF INTERNAL REVENUE
Quezon City
September 2023 Version
ANNEX “J.5”
QF-TCC-06-04-2023.01
AMENDED
SWORN APPLICATION FOR TAX CLEARANCE
(To be accomplished by the Individual Taxpayer [Sole Proprietor, Professional, Local Employee &
Self-Employed] Securing Tax Clearance for General Purposes)
I, ____________________________________________, Filipino/____________(indicate nationality
for non-Filipino citizenship), of legal age, single/married to_____________________________________,
permanently residing at _____________________________________________________________ with
Taxpayer Identification Number (TIN) __________________________________, after having been duly
sworn in accordance with law hereby depose and state:
1.
That I am the Owner/Proprietor/Proprietress of ____________________________________________
with business address at ______________________________________________________________,
with Telephone/Cellular Phone No. ______________________ and email address ________________;
2.
That my business trade name has been duly registered with the Department of Trade and Industry on
_____________________________ under DTI Registration Certificate No. _____________________;
3.
That I registered my business with BIR under Certificate of Registration No. ______________issued at
Revenue District Office/LTDO No.____________on _______________________________________;
4.
That, the following documentary requirements in relation to the aforesaid application are all authentic
and hereto attached in compliance with the existing policies.
_____ a. One (1) original copy of DELINQUENCY VERIFICATION REPORT (DVR);
_____ b. One (1) piece of loose documentary stamp tax worth P30.00;
_____ c. Confirmation Receipt of Electronic payment of certification fee worth Php 100.00 or other
proof of payment;
_____ d. One (1) original copy of valid and properly accomplished Special Power of Attorney (SPA) signed by
the applicant, applicable only to applications through an authorized representative; and
_____ e. One (1) photocopy of each valid identification cards (any government issued ID) with three
(3) specimen signatures of the applicant and the authorized representative.
5.
That this affidavit is being submitted in order to secure a Tax Clearance Certificate for General Purposes
specifically for ______________________________.
____________________________________________
Signature over Printed Name of Taxpayer-Applicant
SUBSCRIBED AND SWORN to before me this _____ day of ______________________, 20___ in
_______________________________. Affiant exhibited to me his/her valid Government Issued Identification Card
___________________________with ID No. _________________.
Doc. No. __________
Page No. __________
BookNo._________
Series of __________
_____________________________________
Notary Public
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!
Affix
!
!
P30.00
!
! Documentary Stamp Tax !
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Data Privacy Notice: Herein information is intended for Authorized Personnel only. Unauthorized disclosure is punishable by laws, as
mandated by R.A. 10173, also known as the Data Privacy Act of 2012, and Section 270 of the National Internal Revenue Code (NIRC) in
handling/processing of BIR data/information.