Payer

(Unit or

Person)

Code:      Tel:

Full Name:

Deposit Bank:

Budget Item

Category:

Item:

Level:

At the Municipal level

Account No.

Receiving Treasury:

Municipal__________

Period for Tax Payment:

Deadline For Tax Payment:

Tax Category

Taxable Amount or Income from Sales

Tax Rate or

Unit Tax

Rate

Amount Paid

or Deducted

Amount of Actual Payment

Income from Salary & Wage

Income from Dividents

Total Amount

(in words)

Twenty-five Thousand Eight Hundred Thirty-one yuan only

Payer (Unit or person) (seal)

Prepared by: (Seal)

Tax Revenue Sub-Bureau of the Local Taxation Authority of

×××Municipality (Seal)

Filled out by: (Seal)

The above-mentioned amount is duly received and transferred to the account of the payee.

Treasury (Bank): (Seal)

Remark