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[{"$nulls":35}," "]
["Fill in all applicable spaces. Mark all appropriate boxes with an \"X\""]
["1","  For the Year",{"$nulls":19},"2","For the Period"]
[null,"    ( YYYY )",{"$nulls":21},"From     (MM/DD)",{"$nulls":11},"      To  (MM/DD)"]
[{"$nulls":6},"Part I - Employee Information",{"$nulls":14},"Part IV-B Details of Compensation Income and Tax Withheld from Present Employer"]
["3 TIN"]
[{"$nulls":21},"A.  ","NON-TAXABLE/EXEMPT COMPENSATION INCOME"]
["4 Employee's Name (Last Name, First Name, Middle Name)",{"$nulls":16},5,"RDO Code",{"$nulls":17},"Amount"]
[{"$nulls":11}," ",{"$nulls":9},27,"Basic Salary(including the exempt P250,000 & below)"]
[{"$nulls":22},"of the Statutory Minimum Wage of the MWE"]
["6 Registered Address",{"$nulls":16},"6A Zip Code",{"$nulls":3},28,"Holiday Pay (MWE)"]
[]
[{"$nulls":21},29,"Overtime Pay (MWE)"]
["6B Local Home Address",{"$nulls":16},"6C Zip Code"]
[{"$nulls":21},30,"Night Shift Differential (MWE)"]
[]
["6D Foreign Address",{"$nulls":16},"6E Zip Code",{"$nulls":3},31,"Hazard Pay (MWE)"]
[]
[{"$nulls":21},32,"13th Month Pay and Other Benefits"]
["7  Date of Birth (MM/DD/YYYY)",{"$nulls":11},"8  Telephone Number",{"$nulls":9},"(maximum of P90,000)"]
[{"$nulls":21},33,"De Minimis Benefits"]
[]
["9  Statutory Minimum Wage rate per day",{"$nulls":20},34,"SSS, GSIS, PHIC & Pag-ibig Contributions"]
[{"$nulls":21}," ","and Union Dues (Employee share only)"]
["10  Statutory Minimum Wage rate per month",{"$nulls":20},35,"Salaries & Other Forms of Compensation"]
[]
[11,null,"   Minimum Wage Earner whose compensation is exempt from ",{"$nulls":18},36,"Total Non-Taxable/Exempt Compensation"]
[null,null,"   withholding tax and not subject to income tax",{"$nulls":18}," ","Income (Sum of Items 27 to 35)"]
[{"$nulls":6},"Part II - Employer Information (Present)"]
["12 Taxpayer",{"$nulls":20},"B.","TAXABLE COMPENSATION INCOME REGULAR"]
[]
["13 Employer's Name ",{"$nulls":20},37,"Basic Salary"]
[]
[{"$nulls":21},38,"Representation"]
["14 Registered Address",{"$nulls":16},"14A Zip Code"]
[{"$nulls":21},39,"Transportation"]
[]
["15 Type of Employer",{"$nulls":8},"Main Employer",{"$nulls":5},"Secondary Employer",{"$nulls":5},40,"Cost of Living Allowance (COLA)"]
[]
[null,null,"Part III - Employer Information (Previous)",{"$nulls":18},41,"Fixed Housing Allowance"]
["16 TIN"]
[{"$nulls":21},42,"Others (Specify)"]
["17 Employer's Name ",{"$nulls":21},"42A"]
[]
[{"$nulls":22},"42B"]
["18 Registered Address",{"$nulls":16},"18A Zip Code"]
[]
[{"$nulls":22},"SUPPLEMENTARY"]
[{"$nulls":4},"Part IVA - Summary"]
[19,"Gross Compensation Income from Present",{"$nulls":19},"43","Commission"]
[null,"Employer (Sum of Items 36 and 50)"]
[20,"Less:  Total Non-Taxable/Exempt Compensation",{"$nulls":19},44,"Profit Sharing"]
[null,"Income from Present Employer (From Item 36)"]
[21,"Taxable Compensation Income from Present",{"$nulls":19},45,"Fees  Including  Director's Fees"]
[null,"Employer (Item 19 Less Item 20) (From Item 50)"]
[22,"Add: Taxable Compensation Income from",{"$nulls":19},46,"Taxable 13th Month Pay Benefits"]
[null,"Previous Employer, if applicable"]
[23,"Gross Taxable Compensation Income",{"$nulls":19},47,"Hazard Pay"]
[null,"(Sum of Items 21 and 22)"]
[24,"Tax Due",{"$nulls":19},48,"Overtime Pay"]
[]
[25,"Amount of Taxes Withheld",{"$nulls":19},49,"Others (Specify)"]
[null,"25A","Present Employer",{"$nulls":19},"49A"]
[]
[null,"25B","Previous Employer",{"$nulls":19},"49B"]
[]
[26,"Total Amount of Taxes Withheld as adjusted",{"$nulls":19},50,"Total Taxable Compensation Income"]
[null,"(Sum of Items 25A and 25B)",{"$nulls":20},"(Sum of Items 37 and 49B)"]
[]
[null,null,"I/We declare, under the penalties of perjury, that this certificate has been made in good faith, verified by us, and to the best of my/our knowledge and belief, is true and correct pursuant to"]
[null,"the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof. Further, I/we give my/our consent to the processing of my/our information"]
[null,"as contemplated under the *Data Privacy Act of 2012 (R.A. No. 10173) for legitimate and lawful purposes."]
[]
[null,null,51]
[{"$nulls":4},"Present Employer/ Authorized Agent Signature Over Printed Name",{"$nulls":16},"Date Signed"]
[]
[null,"CONFORME:"]
[]
[null,null,52,{"$nulls":18},"Date Signed"]
[{"$nulls":4},"Employee Signature Over Printed Name",{"$nulls":31},"Amount Paid, if CTC"]
[null,"CTC/Valid ID No.",{"$nulls":9},"Place of ",{"$nulls":9},"Date of Issue"]
[null,"of Employee",{"$nulls":9},"Issue"]
["To be accomplished under substituted filing"]
[null,"I declare, under the penalties of perjury,  that the information herein stated are reported ",{"$nulls":19},"  I declare,under the penalties of perjury that I am qualified under substituted filing of "]
["   under BIR Form No. 1604C which has been filed with the Bureau of Internal Revenue.",{"$nulls":20},"Income Tax Returns(BIR Form No. 1700), since I received purely compensation income"]
[{"$nulls":21},"from  only  one  employer  in  the  Philippines for  the calendar  year; that  taxes have been "]
[{"$nulls":21},"correctly withheld by my employer (tax due equals tax withheld);  that the  BIR Form  "]
[null,53,{"$nulls":19},"No. 1604-C filed by  my  employer to the BIR shall constitute as my income tax return;"]
[null,"Present Employer/ Authorized Agent Signature Over Printed Name",{"$nulls":19},"and that BIR Form No. 2316 shall serve the same purpose as if BIR Form No. 1700  "]
[null,"(Head of Accounting/ Human Resource or Authorized Representative)",{"$nulls":19},"has been filed pursuant to the provisions of Revenue Regulations (RR) No. 3-2002, as amended."]
[]
[{"$nulls":23},54]
[{"$nulls":24},"Employee Signature Over Printed Name"]
["*NOTE: The BIR Data Privacy is in the BIR website (www.bir.gov.ph)"]