LANDBANK

_________________________Branch
ETAX PAYMENT ENROLLMENT FORM
New Enrollment
TERMS
Updates(Please check the appropriate box for updates) Change Password Change Authorized Enrollee Additional Authorized Enrollee
Enrollment Date ______ Change Registered Name Change Account Number Additional Account Number Change email address Change Tin
REGISTERED NAME/ TAXPAYER’S NAME (Write in print) AND RDO TIN (Indicate the 12 digit number)
Individual NGA/SUC
CONDITI
Corporate LGU - - -

TAXPAYER’S ADDRESS (Write in Print)

ONS CONTACT NO. E-TAXPAYER’S BRANCH CODE
(to be provided by BIR)

NAME OF AUTHORIZED ENROLLEE (Write in print) Any one(1) E-MAIL ADDRESS (Write in print, case sensitive, the number zero should USER ID (Write in print, 4 character Alpha or numeric or
Any two(2) be written as “Ø” to differentiate from the letter “O”) combination)

1. __________________________________________________ 1._______________________________________ 1. ______________________________

2. __________________________________________________ 2. _______________________________________ 2. ______________________________
3. __________________________________________________ 3. _______________________________________ 3. ______________________________
4. __________________________________________________ 4. _______________________________________ 4. ______________________________
ACCOUNT NUMBER/S TO BE ENROLLED (Please attached separate sheet for other account nos.)
SAVING ACCOUNT CURRENT ACCOUNT
1. - - 1 - -
.
2. - - 2 - -
.
DEPOSITORY’S SIGNATURE
I/we hereby agree to the terms and conditions governing the E-Tax Payment Facility to LANDBANK:

______________________________ ______________________________ ______________________________ ______________________________

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
For corporate taxpayer, a Board Resolution authorizing enrollment of the account(s) , and designating authorized enrollee/password holders shall be required. It is the responsibility of the Board of Director/ Trustees of the corporation to inform the bank of change in authorized enrollees.
FOR BRANCH USE FOR MCMD ENROLLMENT
This is to certify that all details and information written above are true, accurate and complete per validation with other required documents submitted
by the clients. Copies of documentary requirements are safekept in the branch for reference.
Verified by Enrolled by Checked by Approved by
Signature Verified by Processed by Approved by ____________________ ____________________ ____________________ ____________________

________________________ ________________________ ________________________

DATE AND TIME RECEIVED: ___________________
Distribution: Copy 1: MCMD Copy 2: Branch/EO Copy 3: Taxpayer

A. Service Terms and Conditions 2.I/We understand that I/We shall be solely held responsible for the adequate security and precautionary
1.The Service will be available to Me/Us upon approval by You of My/Our enrollment under the facility. measures in order that at all times the Facility shall only be furnished and disclosed to our authorized
 personnel. As such, I/We shall not under any circumstances disclose My/Our user's password on the E. Protecting My/Our Account
Facility. I/We understand My/Our role in the prevention of any wrongful use of My/Our account. I/We shall be responsible in
promptly examining My/Our confirmation advice sent thru E-Mail. If I/We find that My/Our records and Yours disagree,
3.I/We acknowledge that you shall be entitled to treat any notice, instructions or other communications
I/We shall immediately inform LANDBANK Customer Care Center at telephone number (02)8405-7000 or PLDT
which from time to time be, or purports to be given thru the internet, telephone, facsimile or other
Domestic Toll-Free number 1-800-10-405-7000. The password that is used to gain access to the Facility shall at all times
electronic means by Us. You shall also be entitled to take such steps in connection with or upon reliance
be kept confidential by Me/Us. I/We shall be responsible for keeping My/Our password, account numbers and other
therefrom.
account data confidential. If I/We believe that My/Our E-Tax Payment password has been lost or stolen, or that someone
4.I/We hereby agree not to hold you liable for any loss, damage or expenses which I/We may incur as a has used it without our permission, we shall notify LANDBANK Customer Care Center at telephone number (02)8405-
result of or in connection to the implementation of the e-Tax Payment Transactions in the following 7000 or PLDT Domestic Toll-Free number 1-800-10-405-7000.
instances:
F. Laws, Rules and Amendments
a. Disruption, failure or delay relating to or in connection with the Services which are due to 1.The Facility shall be subject to Your (i) present and future policies (ii) the applicable rules and
circumstances beyond your control, unforeseen events, fortuitous events such as but not limited to regulations relative to the establishment and operation of the Facility.
prolonged power outages, breakdown in computers and communication facilities, typhoons, floods,
2.You are entitled to revise or modify all or any of these Terms and conditions.
public disturbances and calamities and other similar or related cases.
b.Loss and damage suffered by us arising out of any fraudulent access or utilization of the e-Tax G. Effectivity of Other Terms and Conditions
Payment System due to theft or unauthorized disclosure of IDs, passwords or violation of other The Terms and conditions governing My/Our other accounts with you shall remain in full force and
security measures used for the e-Tax Payment Facility with or without our participation. effect insofar as the same is not inconsistent herewith.
c. Inaccurate, incomplete or delayed information received by the Taxpayer Enrollee due to disruption or H. Acceptance of Terms and Condition
failure of any communication facilities used for the System. By utilizing Your facility described herein, I/We hereby acknowledge and confirm to have read,
d.In case of insufficiency of fund at the time of receipt of payment instructions. understood and agreed to be bound by these Terms and Conditions and any future amendments thereto,
5.You shall not be liable for any indirect, incidental or consequential loss, loss of profit or damage suffered and other materials as maybe provided by You.
by the Taxpayer Enrollee by reason of its use or failure or inability to use the Facility.
6.I/We agree that My/Our e-Tax Payment instruction received after 10:30 p.m. or Saturday, Sunday and
_________________________________ _________________
Holidays shall be considered as a transaction of the following banking day.
Enrollee’ Signature Above Printed Name Date
7.I/We understand that the confirmation issued to Me/Us by the BIR is equivalent to the acknowledgement
receipt issued by You that is, it is an acknowledgement of My/Our e-Tax Payment Instruction and not
necessarily a confirmation that My/Our e-Tax Payment has been successful or has been accepted. _________________________________ _________________
8. I/We agree that My/Our Payment shall be deemed duly accepted upon your issuance to Me/Us of a
Enrollee’ Signature Above Printed Name Date
confirmation advice the day following your issuance of the above -mentioned acknowledgment receipt.
9.I/We fully understand also that should My/Our e-Tax Payment be accepted/confirmed by You , You shall _________________________________ _________________
cause the value dating of My/Our e-Tax Payment on the day of your acknowledgement of our e-Tax Enrollee’ Signature Above Printed Name Date
Payment instruction .I/We understand also that You in coordination with the Bureau of Internal Revenue
(BIR) are entitled to withdraw and/or vary and/or enhance any feature of the Service or to cancel My/Our ________________________________ _________________
enrollment on the Facility upon prior notice to Us.
Enrollee’ Signature Above Printed Name Date
B. Charges
Enrollment and availment of the service is free of charge. You reserve the right to impose service fees,
and other charges in accordance with Your standing and future policies and to change or amend the same
upon prior notice to Me/Us. Such charges shall be deducted from My/Our account.
C. Service Availability
1.The Facility will immediately be available upon approval by you of My/Our enrollment.
2.The availability of the Facility shall also be subject to the Terms and Conditions from time to time
contained in notices posted in your branches, or information leaflets relating thereto available in your
branches.
D. Change/Replacement of Password
I/We may change My/Our password from time to time upon filling out the E-Tax enrollment Form.