ANNEX"A"
SWORN DE UON OF
GROSS REJ.VllTl'ANCES
(For Sellers/Merchants Engaged in Business within Electronic Marketploces)
r.
,,,,.,....-
,., -,----,.,,...,,....,...,.-,--, ------------- oflegal age with business address
(Nam•of IJ/RllcgutdredSe/lef'/Mqc/1an1)
looatedat
and Taxpayer
Identification Number (ITN)
,, ----------- ' after having been duly sworn in.accordance with law
hereby depose and state:
1. That I derive my inc0tne from sale of goods and services from Etectroaic Marketplace and/or Digital Financial
Services Provider(indicate thenamesof electroniclllllJ'ketplace operators or d gital:financialservices providers).
2. Thatfor the period
_,thegross remittances from thesale ofgoods andservices by
Electronic Matketplace Operators and Digi1al Financial Services Providers
□ Do not exceed Five Hundred Thousand Pesos{¥500,000.00).
□ Exceed Five Hundred Thousand Pesos ('.P500,000.00).
3. That jf at any time during the taxable period, the gross remittances exceed P500,000.00, the Electronic
Marketplace Operator and Digital Financial Services Provider/withholding agents shall automatically withh.old
the rateof onepercent(1%) on the one-half$ of grossremittances for thegoods and servjces sold/paid ough
their platform/facility.
4. That I duly execute this SWORN DECLARATION in compliance with the implementing guidetlnes of
Revenue Regulations No. 16-2023.
5. That I declare, under the penalties of perjmy, thatthis declaration has been made in good faith, and to the best
ofmy knowledge and beliefto be true and correct
IN' WITNESS WHEn.EOF, I have hereunto set my hand thls _
clay of
. 0_
2
at
..,Philippines
Sigmttun,over Printed Nama /11rllvldual 1"a:,payer ar Al11harlud Nltprcrtmtalivo
SUBSCRIBED AND SWORN to before me lhis
day of
2
, 0_
fu
.. Applicant exhibitMto me his/her
at.
r
lloo.:No.:
PageNo.t
Book No.:
criaor
!
on
.
..
Affix1'30,00
I DocumclllllQ' StampTax
L
issued
(Gararrrmmt l=•d II)mulNnJ
I
j
!
,
(To be fllled-cuJ by tllewltl1holtllng agent/lone payor)
DateReceived:
(MM-DD-YYYY:.0000I}
R,eceived by:
Sl,;rm,,m,-rl'rlmtdl{am,'If <l,o IF/0...W"l:J/pmll'ayor.,.J/111/1'1rl""1OjJ/ot,'
Da/,:tlrJlla,tll'o,lllonof ,lulhorl;r:d QJT,-
I{,,,..ofll'illt/.,/dl"l:Apn<!T,:x,c Pap,r