Serv Central 2307 November 2023

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Republic of the Philippines

Department of Finance
Bureau of Internal Revenue

Certificate of Creditable Tax


Withheld at Source
Fill in all applicable spaces. Mark all appropriate boxes with an "X".
1 For the Period From (MM/DD/YYYY) To (MM/DD/YYYY)

Part I – Payee Information

2 Taxpayer Identification Number (TIN)

3 Payee’s Name (Last Name, First Name, Middle Name for Individual OR Registered Name for Non-Individual)

4 Registered Address 4A ZIP Code

5 Foreign Address, if applicable

Part II – Payor Information

6 Taxpayer Identification Number (TIN)

7 Payor’s Name (Last Name, First Name, Middle Name for Individual OR Registered Name for Non-Individual)

8 Registered Address 8A ZIP Code

Part III – Details of Monthly Income Payments and Taxes Withheld


AMOUNT OF INCOME PAYMENTS
Income Payments Subject to Expanded Tax Withheld for the
ATC 1st Month of the 2nd Month of the 3rd Month of the
Withholding Tax Total Quarter
Quarter Quarter Quarter
Rental WC100
Goods WC158 110,027.07 110,027.07 1,100.27
Goods WI158
Services WC160
Services WI160
Professional Fee WC050
Sale of Minerals and Quarry Resources WC630

Total 110,027.07 110,027.07 1,100.27


Money Payments Subject to
Withholding of Business Tax
(Government & Private)

Total

We declare under the penalties of perjury that this certificate has been made in good faith, verified by us, and to the best of our knowledge and belief, is
true and correct, pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof. Further, we
give our consent to the processing of our information as contemplated under the *Data Privacy Act of 2012 (R.A. No. 10173) for legitimate and lawful purposes.

ANDRES A. BELTRAN / PRESIDENT & GENERAL MANAGER


Signature over Printed Name of Payor/Payor’s Authorized Representative/Tax Agent
(Indicate Title/Designation and TIN)
Tax Agent Accreditation No./ Date of Issue Date of Expiry
Attorney’s Roll No. (if applicable) (MM/DD/YYYY) (MM/DD/YYYY)
CONFORME:

Signature over Printed Name of Payee/Payee’s Authorized Representative/Tax Agent


(Indicate Title/Designation and TIN)
Tax Agent Accreditation No./ Date of Issue Date of Expiry
Attorney’s Roll No. (if applicable) (MM/DD/YYYY) (MM/DD/YYYY)
*NOTE: The BIR Data Privacy is in the BIR website (www.bir.gov.ph)

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