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0616 Amnesty Tax Payment Form Pursuant to Republic Act No. 9399

This form is to be accomplished by taxpayer who availed of the One-Time Amnesty on certain tax and duty liabilities, inclusive of fees, fines, penalties, interests and other additions thereto, incurred by certain business enterprises operating within the Special Economic Zones and Freeports pursuant to Republic Act No. 9399.

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(To be filled up the BIR)

PSIC:

PSOC:

Amnesty Tax
Payment Form

Republika ng Pilipinas
Kagawaran ng Pananalapi

Kawanihan ng Rentas Internas

BIR Form No.

0616
April 2007(ENCS)

Pursuant to Republic Act No. 9399
Fill in all applicable spaces. Mark all appropriate boxes with an "X"
2 Date of Filing

1 Year/Period Covered
(MM/DD/YYY)

6

3 Tax Type

(MM/DD/YYYY )

4 ATC

MC

5 No. of Sheets
Attached

MC 290

BCS No./Item No. (To be filled up by the BIR)

Part I
7

Background

Taxpayer Identification No.

Information

8 RDO Code

9 Taxpayer Classification 10 Line of Business
I

11

N

Taxpayer's
Name

12 Telephone Number
(Last Name, First Name, Middle Name for Individuals) / (Registered Name for Non-Individuals)

13 Business/
Trade Name
14 Registered
Address

15 Zip Code

Part II

Computation of Amnesty Tax

16

Amount Due

16A

17

Add: Fines, Penalties & Interest (if applicable)

18

Total Amount Payable (Sum of Items 16A & 17A)

17A

18A

19
I declare, under the penalties of perjury, that this document has been made in good faith, verified by me,
and to the best of my knowledge and belief, is true and correct, pursuant to the provisions of the National
Internal Revenue Code of 1997, as amended, in relation to Republic Act no. 9399, and the regulations issued
under authority thereof.

President/Vice President/Principalof Taxpayer /Authorized Representative of Signatory
Signature over Printed Name Officer/ Accredited
Title/Position
Tax Agent/Authorized Representative/Taxpayer
(Signature Over Printed Name)
Tax Agent Acc. No./Atty's Roll No. (if applicable)

Part III

(RO's Signature/Bank Teller's Initial)

TIN of Signatory

Date of Expiry

Date of Issuance

D e t a i l s of P a y m e n t

Particulars
20 Cash/

Stamp of Receiving Office/
AAB and Date of Receipt

Drawee Bank/Agency
20A

Number

20B

MM

DD

YYYY

Amount

20C

20D

21C

21D

22C

22D

Bank Debit Memo

21 Check 21A

21B

22 Others 22A

17C

22B
19C

GUIDELINES AND INSTRUCTIONS

Who Shall File
This form is to be accomplished by taxpayer who availed of the One-Time Amnesty on certain tax and duty liabilities, inclusive of fees, fines, penalties, interests and other
additions thereto, incurred by certain business enterprises operating within the Special Economic Zones and Freeports pursuant to Republic Act No. 9399.
When and Where to File and Pay
This form shall be filed in triplicate copies and tax shall be paid with any Authorized Agent Banks (AAB) under the jurisdiction of the Revenue District Officer (RDO)/
Large Taxpayers Service (LTS)/ Large Taxpayers District Office (LTDO) that has jurisdiction over the taxpayer. In the absence of an AAB, payment may be made with the
Revenue Collection Officer/Deputized Treasurer of the RDO that has jurisdiction over the taxpayer. The Revenue Collection Officer/Deputized Treasurer shall issue a
Revenue Official Receipt (ROR) therefor.
Where this form is filed with an AAB, the taxpayer must accomplish and submit BIR-prescribed deposit slip, which the bank teller shall machine validate as evidence that
payment was received by the AAB. The AAB shall stamp mark this form with the word "Received" and also machine validate it as a proof of receipt of the payment of the
taxpayer. The machine validation shall reflect the date of payment, amount paid and transactions code, the name of the bank, branch code, teller's code and teller's initial.
Bank debit memo number and date should be indicated in the form for taxpayers paying under the bank debit system.
Computation of the Amnesty Tax
Amnesty tax to be paid is twenty-five thousand pesos (P25,000.00).
Note:
This form shall be filed and be paid within six (6) months from the effectivity of Republic Act No. 9399.

Machine Validation/Revenue Official Receipt Details (If not filed with the bank)

Taxpayer Classification:

I - Individual

N - Non-Individual
 
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