Federal Democratic Republic of The National Regional Government of
Ethiopia
Pension Contribution Declaration Form
Oromia
Proclamation No. 715/2011
Ethiopian Revenues & (Private Organization Employees Pension
Custom Authority Proclamation) Bureau of Revenues
1. Taxpayer Name.(Company Name Your Name ,Father’s 3. Taxpayer Identification Number 4. Tax Account Number 8. Tax Period: Page 1 of ___
Name, Grandfather’s Name 0015208622 MonthMeg Year
9865900922 abit 2013
Ayantu Kenea
2a. Region 2b. Zone/K-Ketema 5. Tax Center Burayu Document Number (Official Use Only)
14 Liyu Zone
2c. 2d. Kebele/Farmers 2e. House No. 6. Telephone Number 7. Fax Number
Woreda Association
Section 1 – Taxpayer Information
f) Pension g) Pension
c) Employee Name(Name, e) Basic h) Total Amount of the contribution
b) Employee d) Start Date of Employment Contribution of Contribution of
a) Seq Num Father’s Name and
(DD/MM/YY)
Salary
Employee __ Employer __%
__% /Birr/ (f + g )
TIN
Grandfather’s Name) /Birr/
% /Birr/ /Birr/
Zelalem Jeno 1500 105 165 270
Transfer Totals from All Continuation
Sheets to this Line >>
Total
(line 20) (line 30) (line 40) (line 50)
Section 2 – Declaration Details
Section 3 – Calculation of Pension Cont. for this Period Section 4 – Employees Removed from Payroll as of this month For Official Use Only
Number of Employees on Your Payroll 1 Seq Employee Employee’s Name
10 Date of Payment
for this Tax Period Num TIN (Name, Father’s Name, Grandfather’s Name)
Total Salary 1500
20 Receipt Number
(From Column e Above)
Total Pension Contribution of Employee 105
30 Amount of Payment
(From Column f Above)
Total Pension Contribution of Employer 165
40 Cheque Number
(From Column g Above)
Total Amount of the contribution this 270
50 Cashier’s Signature
month (From Column h Above)
Section 5 – Taxpayer Certification
I declare that the above declaration and all information provide here-with Taxpayer or Authorized Agent name _________ Employ For tax Officer: Name _____________
(including continuation sheets) is correct and complete. I understand that any Signature _____________ er Seal Signature _________
misrepresentation is punishable as per the tax Laws and the Penal code. Date ______________ Date ____________
The National Regional Government of Oromia Bureau of Revenue OBR Form ------ (G1/2011)
Pension Contribution
Federal Democratic Republic of Ethiopia Declaration Form The National Regional Government of
Ethiopian Revenues & Proclamation No. Oromia
715/2011
Custom Authority (Private Organization Employees Bureau of Revenues
Pension Proclamation)
Section 1 – Taxpayer Information
1. Taxpayer Name.(Company Name Your 3. Taxpayer Identification Number 8. Tax Period:
Name ,Father’s Name, Grandfather’s Name 0015208622 Month Megabit Year 2013 Page 1 of ___
Ayantu Kenea
Section 2 – Declaration Detail
g) Pension
f) Pension h) Total Amount of the
d) Start Date of e) Basic Contributio
c) Employee Name(Name, Father’s Name Contribution of contribution __% /Birr/
a) Seq Num b) Employee TIN Employment Salary n of
and Grandfather’s Name) Employee __ (f + g )
(DD/MM/YY) /Birr/ Employer
% /Birr/
__% /Birr/
Zelalem Jeno 1500 106 165 270
Transfer Totals
from All
Taxpayer name & Seal Continuation
Sheets to this
Line >
Total
(line 20) (line 30) (line 40) (line 50)
The National Regional Government of Oromia Bureau of Revenue (as of /5/2011) OBR Form _____ (1/2011)
