Sworn Statement of Income: SUBSCRIBED AND SWORN TO Before Me This - Day of - , 2013

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SWORN STATEMENT OF INCOME

(MARGINAL INCOME EARNER)

I am _________________________________________________________________, residing at
(indicate full name, middle name and surname)

____________________________________________________________.
(indicate complete address)

I am not employed and I am not earning any compensation income.

I am currently _________________________________________________. This activity is my


(indicate type of business, e.g. Copra Farmer, Fishermen, Sari-Sari Store or Carinderia Owner, etc.)

principal source of subsistence and livelihood and my gross sales/receipts in a 12-month period does not

exceed one-hundred thousand pesos (P100,000.00).

___________________________________
Taxpayer
(Signature over Printed Name)

__________________
Date

I attest to the identity of herein named taxpayer.

___________________________________
Witness attesting to identity of taxpayer
(Signature over Printed Name)
(i.e. Barangay Chairman)

SUBSCRIBED AND SWORN TO before me this ___________ day of ______________, 2013,


affiant exhibiting his Community Tax Certificate No. __________ issued at _______________________
on ______________.

___________________________________
BIR Revenue Officer
(Signature over Printed Name)

Note: This form should be translated in local dialect if necessary to make taxpayer-registrant properly understand the content of this
declaration.

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