ANNEX D
SWORN DECLARATION
REPUBLIC OF THE PHILIPPINES
PROVINCE OF PALAWAN
CITY/MUNICIPALITY OF PUERTO PRINCESA
I, Bernalene B. Lim, Filipino, of legal age designated as Owner of Kelsie’s Chaolong Bistro with
business address located at RBO Bldg., Bgy. Sicsican, Puerto Princesa City, Palawan, do hereby
certify the following:
      That in compliance with Section 13 of Revenue Regulations No. V-1, otherwise known as
       the Bookkeeping Regulations, submitted herewith is the DVD-R containing the summary
       list(s) / schedule(s) of inventory (stocks-in-trade, materials, supplies and other goods ,
       etc.) and/or other schedules _____(applicable schedules)________ as of taxable year
       ending December 31, 2024.
      That the contents of the DVD-Rs being submitted herewith conform to the prescribed
       format as required by the Bureau of Internal Revenue under Revenue Memorandum
       Circular No. 57-2015.
      That the summary list(s)/ schedule(s) of inventory and/or other schedules has been
       made in good faith, verified by us, and to the best of our knowledge and belief, is true
       and correct pursuant to the provisions of the NIRC, as amended, and the rules and
       regulations and other revenue issuances issued under authority thereof.
I HEREBY DECLARE UNDER THE PENALTIES OF PERJURY THAT THE FOREGOING ATTESTATIONS
ARE TRUE AND CORRECT.
                                                                  BERNALENE B. LIM
                                                           Name and Signature of Authorized
                                                                   Representative
                                                           TIN: 327-404-875-000
      SUBSCRIBED and sworn to before me, in the City/Municipality of ______, this day of
____, 20___ by ________________ with Residence Certificate No. __________ issued at
___________, on _________ 20___.
                                                                  Notary Public
Doc. No.____
Page No. ____
Book No. ____
Series of ____