Tuesday, May 20, 2014

Sample Affidavit for BIR Revenue Regulation No. 4-2014





Republic of the Philippines                 )

City/Municipality of _____________  )

 

 

AFFIDAVIT

 

 

            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 __________________________.

 

                                                                                            Name

Affiant

                                                                    

            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.

Hope this helps. http://myaddressisearth.blogspot.com/
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