Federal Democratic Republic of Ethiopia Excise Tax Declaration Form The National Regional Government of Oromia
Ethiopia Revenues & Custom (To Be Filled Monthly) Bureau of Revenues
Authority
Section 1 – Taxpayer Information
1. Taxpayer’s Name (Company Name or Name, Father’s Name, Grandfather’s Name) 3. Taxpayer Identification Number 4. Tax Account Number 8. Tax Period
Month Year Page 1_ of_
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 Tax Due
b) e) i)
d) g) h)
a)Seq Category of Product / Parent Product Monthly f) Unit Cost Tax to Pay
c) Product Details Measure Cost of Production Excise Tax
Num (See Reverse for Listing of Product Categories and Tax Production (Birr) (Column g x h)
ment (Column e x f) Rate
Rates) (units) (Birr)
Totals from Attached Continuation Sheets if used
Total Line 10 > Line 20>
Section 3 – Taxpayer Certification For Official Use Only
I declare that the above declaration and all information provided here-with is correct and complete to the best of my knowledge and
Date of Receipt
belief. I understand that any misrepresentation is punishable under the appropriate tax laws and penal code. Declaration of preparer
Payment Number
(other than the taxpayer) is based on all information of which the preparer has any knowledge.
Printed Name of Taxpayer or Authorized Officer Signature of Taxpayer or Authorized Officer Date Amount of Cheque
Payment Number
Company Seal
Printed Name of Preparer Signature of Preparer Date Cashier’s Signature
Oromia Bureau of Revenues (Draft as of 4/11/2006) OBR Form 2101 (5/2006)
