Payer

(Unit or

Person)

Code:

Full Name:

Address:

Withholding Agent

Code:

Full name:

Address:

Period for Tax Payment:

Tax Category

Taxation Items

Taxation

Quantity

Taxable Amount

Tax Rate or

Unit Tax

Amount

Amount  Deducted

Amount of Actual Payment

Income Tax

Salary

Total Amount

(in words)

Two Thousand Three Hundred and Eight yuan only

Competent

Taxation Agency:

(Special seal for

Tax Payment,

×××Municipal Local Taxation Bureau,

External Affairs Branch, No.××)

Withholding Agent:

Filled out by:

Remark