RECEIPT FOR EARNED INCOME TAX WITHHOLDING

Control No.

RESPONSIBLE PERSON FOR TAX WITHHOLDING

1.  Business Registration No.:

2.  Name of Corporation:

3.  Name of Representative:

4.  Resident Registration No.:

5.  Address:

TAXPAYER

6.  Name in full:

7.  Resident Registration No.:

8.  Address:

9.   Period of Fiscal Year:

10.  Period of Reduction:

DETAILS OF INCOME BY EMPLOYER

11. Employer:

111. Present Employer

112. Prior Employer

114. Total

12. Name of Employer:

13. Business Registration No.:

14. Salary Total:

15. Bonus Total:

16. Total:

NONTAXABLE INCOME

17. Work Abroad:

18. Good Attendance Allowance:

19. Overtime Allowance Etc.:

20. Miscellaneous:

21.  Salary of Last Month:

DETAILS OF ADJUSTMENT

22.  Amount of Earned Income:

DEDUCTION OF EXPENSES

23. Insurance Bill:

24. Medical Expenses:

25. Educational Expenses:

26. Worker without House:

27. Couple Working together:

28. Earned Income:

29. Total:

30.  Amount of Earned Income (22-29):

31.  Income Deduction for Pension:

32.  Income Deduction:

33.  Special Deduction for Donation:

34.  Tax Basis of Composite Income:

35.  Computed Tax Amount:

DEDUCTION OF TAX AMOUNT

36. Tax Payment Abroad:

37. Earned Income:

38. Property Accumulation Savings:

39. Savings for Employee Stock:

40. Fund for Residential House:

41. Work Abroad:

42. Work in US Armed Forces:

43. Security Savings:

44. Total Deduction of Tax Amount:

REDUCTION OF TAX AMOUNT

45. Income Tax Act:

46. Tax Reduction Act:

47. Total Reduction of Tax Amount:

PAID TAX AMOUNT	Income Tax	Resident Tax

48. Determined Taxes (35-44-47):

49. Withheld Taxes at Prior Employer:

50. Withheld Taxes at Present Employer:

51. Balance of Taxes:

DETAILS OF INCOME DEDUCTION

52.  Basic Deduction:

53.  Spouse:

54.  Dependents ( ):

55.  Disabled Person ( ):

56.  Aged Dependents ( ):

57.  Female Householder:

58.  Income Deduction Total:

I hereby acknowledge the receipt of above-listed withholding tax amount.

Date:

RESPONSIBLE PERSON FOR TAX WITHHOLDING

Official Seal Affixed