Tuesday, May 20, 2014

Sample Affidavit for BIR Revenue Regulation No. 4-2014

Republic of the Philippines                 )

City/Municipality of _____________  )






            I, ________________ , of legal age, Filipino, single, with business address at Suklayin, Baler, Aurora after having been duly sworn to in accordance with the law, hereby depose and say that:


1.    That I am a Medical Doctor by profession and registered with the Bureau of Internal Revenue RDO __, Municipality of _____________ with Tax Identification No. ____________________.


2.    That I am currently holding clinic at ____________________________.


3.    That on March 3, 2014, the Bureau of Internal Revenue released Revenue Regulation No. 4-2014 Guidelines and Policies for the Monitoring of Service fee of Professionals;


4.    That I charge the following professional fees to my patient:

a)    Consultation fee – Php XXX

b)    Surgical cases are based on relative value score (RVS) x

c)    Medical cases are based on room rates x


The above-rates would vary depending on the classification, relation of patient, difficulty of cases, length of service, and complications arising from condition.


5.    That the manner of billing for in-patients is through the hospital; while for out-patient is through the clinic.


6.    That professional fees paid by Senior Citizens/PWDs are discounted by 20%;


7.    That I am executing this affidavit to attest to the veracity of the foregoing facts and for all intents and for whatever legal purpose it may serve.


IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of ___________, at __________________________.





            SUBCRIBED AND SWORN to before me, in ____________, this __________ day of _________________ with Community Tax Certificate No. _____________________ issued at __________________ on _________________.



                                                                                                            NOTARY PUBLIC


Doc No.     _______

Page No.    _______

Book No.    _______

Series of 2014.

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