NOTICE OF AVAILMENT OF TAX AMNESTY Under Republic Act No. 9480

This form shall be accomplished in duplicate by Individuals, whether resident or nonresident citizens, or resident or nonresident aliens, Estates, Trusts, Corporations, Cooperatives and tax exempt entities that have become taxable as of December 31, 2005 and other juridical entities including partnerships liable to pay any internal taxes covering the taxable year ending December 31, 2005 and prior years, availing the Tax Amnesty under R.A. No. 9480.

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Under Republic Act No. 9480

___________________________
(Date)
The Commissioner of Internal Revenue
BIR National Office Building
Diliman, Quezon City
Attention: Revenue District Officer ______________________
Revenue District Office No. ___________________
Revenue Region No. _________________________
Sir/Madam:
I/We hereby notify your Office that _______________________________________________________ __________,
(Name of Taxpayer)

with TIN __________________ and registered address at _______________________________________________________
______________________________ would like to avail of the tax amnesty under R.A. No. 9480, as implemented by
Department Order No. 29-07.
Attached are the required documents:
1.

Statement of Assets, Liabilities and Networth (SALN) as of December 31, 2005
Without previous SALN /Balance Sheet

With previous SALN /Balance Sheet

- SALN as of December 31, 2005

- Original declaration
- Amended declaration

2.
3.

Tax Amnesty Return (BIR Form No. 2116)
Tax Amnesty Payment Form/Acceptance of Payment Form (BIR Form No. 0617)

I declare under the penalties of perjury, that this statement and the attached documents mentioned above have been
made in good faith, verified by me and I attest to the correctness and completeness of the declaration therein.

_____________________________
President/Vice President/Principal Officer/
Authorized Representative/Taxpayer
(Signature Over Printed Name)

Stamp of Receiving Office and Date of Receipt
(RO’s Signature Over Printed Name)

_________________________