Federal Democratic Republic of Ethiopia Schedule A The National Regional Government of Oromia

Employment Income Tax Declaration

Ethiopian Revenues &
Custom Authority Bureau of Revenues
Section 1 - Taxpayer Information

1. Taxpayer’s Name (Company Name or Your Name, Father’s Name, Grandfathers Name) 3. Taxpayer Identification Number 4. Tax Account Number 8. Tax Period:
Month Year Page 1 of 1

2a. Region 2b. Zone/K-Ketema 5. Tax Center Document Number (Official Use Only)

2c. Woreda 2d. Kebele/Farmers Association 2e. House Number 6. Telephone Number 7. Fax Number

Section 2 – Calculation of Payments to Employees

Additional Benefits
c) Employee Name j) Taxable
b) d) Start Date f) Total
a) Seq (Name, Father’s Name e) Basic g) Taxable i) Other Income l) Cost m) Net n) Employee
Employee of Transportation h) Over k) Tax Withheld
Num and Grandfather’s Salary Transportatio Taxable (Sum Columns Sharing Pay Signature
TIN Employment Allowance Time
Name) n Allowance Benefits e, g, h, and i)

Transfer Totals from All Continuation Sheets to this Line >>

Total
(line 20) (line 30)
Section 3 – Calculation of Tax Due this Period Section 4 – Employees Removed from Payroll as of this month For Official Use Only
Number of Employees on Your Payroll for this Tax Period Seq Employee’s Name
10 Employee TIN Date of Payment
Num (Name, Father’s Name, Grandfather’s Name)
Total Taxable Income
20 Receipt Number
(From Column j Above)
Total Tax Withheld
30 Amount of Payment
(From Column k Above)

Cheque Number

Cashier’s Signature
Section 5 – Taxpayer Certification

I declare that the above declaration and all information provide here-with (including continuation sheets) is correct and Printed Name Signature & Date of Authorized Employer Seal Preparers Printed Name, Signature & Date
complete. I understand that any misrepresentation is punishable as per the tax Laws and the Penal code. Declaration of Officer
preparer (other than the taxpayer) is based on all information of which the preparer has any knowledge.

The National Regional Government of Oromia Bureau of Revenue

 Federal Democratic Republic of Ethiopia Schedule A The National Regional Government of Oromia
Employment Income Tax Declaration
Ethiopian Revenues & Bureau of Revenues
Custom Authority 
Section 1 - Taxpayer Information 
1. Taxpayer’s Name (Company Name or Your Name, Father’s Name, Grandfathers Name) 3. Taxpayer Identification Number 4. Tax Account Number 8. Tax Period:
Page 1 of
Month Year ___
2a. Region 2b. Zone/K-Ketema 5. Tax Center Document Number (Official Use Only)

2c. Woreda 2d. Kebele/Farmers Association 2e. House Number 6. Telephone Number 7. Fax Number

Section 2 – Calculation of Payments to Employees

Additional Benefits
d) Start Date f) Total j) Taxable Income n)
a) Seq c) Employee Name (Name, Father’s g) Taxable i) Other l) Cost
b) Employee TIN of e) Basic Salary Transportation h) Over (Sum Columns e, k) Tax Withheld m) Net Pay Employee
Num Name and Grandfather’s Name) Transportation Taxable Sharing
Employment Allowance Time g, h, and I ) Signature
Allowance Benefits

Transfer Totals from All Continuation Sheets to this Line >>

Total
(line 20) (line 30)
The National Regional Government of Oromia Bureau of Revenue