BIR Form No.

1701v2018 Page 1 of 2

BIR Form No.

Annual Income Tax Return
1701 Individuals (including MIXED Income Earner), Estates and Trusts
January 2018 (ENCS) Enter all required information in CAPITAL LETTERS using BLACK ink. Mark all applicable boxes
Page 1 with an "X". Two copies MUST be filed with the BIR and one held by the Tax Filer.

1 Month 12 For the Year (YYYY) 2021 2 Amended Return? Yes No 3 Short Period Return? Yes No

PART I - BACKGROUND INFORMATION OF TAXPAYER/FILER

4 Taxpayer Identification Number (TIN) 117 - 240 - 062 - 000 5 RDO Code 018

6 Taxpayer Type Single Proprietor  Professional Estate Trust Compensation Earner

7 Alphanumeric Tax Code (ATC) II012 Business Income-Graduated IT Rates II014 Income from Profession-Graduated IT Rates II013 Mixed Income-Graduated IT Rates

II011 Compensation Income II015 Business Income-8% IT Rate II017 Income from Profession-8% IT Rate II016 Mixed Income-8% IT Rate

8 Taxpayer's Name (Last Name, First Name, Middle Name)/ESTATE OF (First Name, Middle Name, Last Name)/TRUST FAO: (First Name, Middle Name, Last Name)
FABIAN, BERNABE GARCIA

9 Registered Address (Indicate complete address. If the registered address is different from the current address, got to the RDO to update registered address by using BIR Form No. 1905)
1095 RIZAL AVE WEST TAPINAC OLONGAPO CITY

9A ZIP Code 2200

10 Date of Birth (MM/DD/YYYY) 11 Email Address

06/11/1956 crisnacino.cancpa@gmail.com

12 Citizenship 13 Claiming Foreign Tax Credits? 14 Foreign Tax Number, if applicable

FILIPINO Yes No

15 Contact Number (Landline/Cellphone No.) 16 Civil Status (if applicable)

2245441 Single Married Legally Separated Widow/er

17 If married, spouse has income? Yes No 18 Filiing Status Joint Filing Separate Filing

19 Income EXEMPT from Income Tax? Yes No 20 Income subject to SPECIAL/PREFERENTIAL RATE? Yes No
[If yes, fill out also consolidation of ALL activities per Tax Regime (Part X)] [If yes, fill out also consolidation of ALL activities per Tax Regime (Part X)]

21A Method of Deduction (choose one)

Graduated Rates
Itemized Deduction Optional Standard Deduction (OSD)
21 Tax Rate* (Choose Method of Deduction in Item 21A)
[Sec. 34(A-J), NIRC] [40% of Gross Sales/Receipts/Revenues/Fees [Sec. 34(L), NIRC]]
(choose one)
8% in lieu of Graduated Rates under Sec. 24(A) & Percentage Tax under Sec. 116 of NIRC
[available if gross sales/receipts and other non-operating income do not exceed Three million pesos (P3M)]

PART II - TOTAL TAX PAYABLE (Do NOT Enter Centavos; 49 Centavos or Less drop down; 50 or more round up)
Particular A. Taxpayer/Filer B. Spouse
22 Tax Due (From Part VI Item 5) 0.00 0.00

23 Less: Total Tax Credits/Payments (From Part VII Item 10) 0.00 0.00

24 Tax Payable/(Overpayment) (Item 22 Less Item 23) 0.00 0.00

Less: Portion of Tax Payable Allowed for 2nd Installment to be paid on or before
25 October 15 (50% or less of Item 22) 0.00 0.00

26 Amount of Tax payable/(Overpayment) (Item 24 Less Item 25) 0.00 0.00

Add: Penalties 27 Interest 0.00 0.00

28 Surcharge 0.00 0.00

29 Compromise 0.00 0.00

30 Total Penalties (Sum of Items 27 to 29) 0.00 0.00

31 Total Amount Payable/(Overpayment) (Sum of Items 26 and 30) 0.00 0.00

32 Aggregate Amount Payable/(Overpayment) (Sum of Items 26 and 30) 0.00

If overpayment, mark one (1) box only. (Once the choice is made, the same is irrevocable)
To be refunded To be issued a Tax Credit Certificate (TCC) To be carried over as a tax credit for next year/quarter

I declare under the penalties of perjury that this return, and all its attachments, have been made in good faith, verified by me, and to the best of my knowledge and belief, are
true and correct, pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof. Further, I give my consent to
the processing of my information as contemplated under the *Data Privacy Act of 2012 (R.A. No. 10173) for legitimate and lawful purposes. (If signed by an Authorized
Representative, indicate TIN and attach authorization letter)

33 Number of Attachments 00
_____________________________________________________________
Printed Name and Signature of Taxpayer/Authorized Representative

PART III - DETAILS OF PAYMENT

Particulars Drawee Bank/Agency Number Date (MM/DD/YYYY) Amount
34 Cash/Bank Debit Memo
35 Check

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BIR Form No. 1701v2018 Page 2 of 2

36 Tax Debit Memo

37 Others (specify below)

Stamp of Receiving Office/AAB and Date of Receipt

Machine Validation/Revenue Official Receipt Details (If not filed with an Authorized Agent Bank)
(RO's Signature/Bank Teller's Initial)

NOTE: *The BIR Data Privacy Policy is in the BIR website (www.bir.gov.ph)

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