AFFIDAVIT

I, ______________________________, Filipino of legal age and with principal registered clinic address at _____________________________________________________________after having duly sworn in accordance with law, do hereby depose and say that:

1. I am taxpayer registered at BIR Regional District Office No.________;

2. I am a Doctor of Dental Medicine practicing my profession in ___________________________________________________________________

3. Pursuant to Revenue Regulation No. 4-2014 (“Guidelines and Policies for the Monitoring of Service Fees of Professionals) of the Bureau of Internal Revenue (BIR), I am formulating the following Professional Fee Menu:

a) Patient Consultation Fee - PhP ______ / consultation

b) Procedures

PROCEDURE | PROFESSIONAL FEES * | | | | | | | | | | | | | | | | | | | | | | |

* Professional fees indicated above is the commission received for every procedure which is 20% of the dental fees 4. The following are my schedule of discounts: Medical / Dental colleagues | 100% discount | Parents and parents in-law of medical / Dental colleagues | 100% discount | Children (legitimate or illegitimate) of medical / Dental colleagues | 100% discount | Legal spouse and common-law partners of medical / Dental colleagues | 100% discount | Senior Citizens | 20% discount | Persons with disability | 20% discount | Hospital co-workers | 50% discount | Relatives (up to first degree of affinity and consanguinity) of hospital co-workers | 10% discount; not applicable if senior citizen or PWD | Medical students, clerks and interns and their parents | 100% discount | Indigent patients including beneficiaries of PantawidPamilyangPinoy Program | 100% discount | Close family friends and relatives | 50% to 100% discount | Discretionary discount to be given on a case to case basis |

5. I am executing this affidavit to attest to the truth of the foregoing facts and in compliance with BIR Revenue Regulation No. 4-2014 only.
AFFIANT FURTHER SAYETH NONE.
IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of April 2014 at Quezon City, Philippines.

____________________________________ Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ___________, 2014, affiant exhibited to me her PRC License No. ______ registered on ___________ at the City of Manila as her competent evidence of identity.

Notary Public
Doc. No. ______
Page No. ______
Book No. ______
Series of 2014