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THE FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA
ETHIOPIAN REVENUE AND CUSTOMS AUTHORITY
Withholding Tax On Payment Declaration
(Income Tax Proclamation No. 286/2002 & Income Tax Regulation No. 78/2002)
Section 1 - Taxpayer Information
1. Name of Person or Organization Withholding Tax
3. Taxpayer Identification Number
4. Tax Account Number8. Withholding PeriodPage 1 of 2
Month Year 2014
2a. Region
2b. Zone/Sub-city
5. Tax CenterDocument Number (Official Use Only)
2c. Woreda
2d. Kebele/Farmer's Asso.
2e. House Number
6. Telephone Number
7. Fax Number
Section 2 - Declaration Details
a) No.b) Withholdee TINc) Name of Organization or Person (Name, Father's Name and Grandfather's Name)d) Withholdee's Address*e) Withholding
Type (Rental of
Buildings/Other)		f) Taxable Amountg) Tax Withheld
((f)x2%)		h) Withholding Tax Receipt
RegionZone/
Sub-city		WoredaKebele/
Farmers Asso.		House No.NumberDate
1
2
3
4
5
6
7
Enter Totals From All Continuation Sheets Here >>
TOTAL Columns f & g (Line 20 and 30)
* Insert "Rental" if the tax is withheld from office or building rent, for other types of transaction please insert "Other"
Section 3 - Calculation of Tax DueSection 4 - Taxpayer CertificationSection 5 - Office Use Only
10Total Number of WithholdeesI declare that the above declaration and all information provided herewith is correct and complete to the best of my knowledge and belief. I understand that any misrepresentation is punishable under the appropriate tax laws and penal code.Date of PaymentReceipt Number
20Total Taxable Amount for this Tax Period (From column f total)Amount of Payment

Check Number
30Total Tax Withheld for this Tax PeriodCashier's Signature
Taxpayer or Authorized Agent
Name
Signature
Date
Withholding Agent Seal
For Tax Office
Tax Officer's Name
Signature
Date
Generated by www.eGenzeb.com ERCA
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THE FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA
ETHIOPIAN REVENUE AND CUSTOMS AUTHORITY
Withholding Tax On Payment Declaration
(Continuation Sheet For Form 1105)
Section 1 - Taxpayer Information
1. Name of Person or Organization Withholding Tax
2. Tax Identification Number
3. Tax Period
Page 2 of 2
Month Year 2014
Section 2 - Declaration Details
a) No.b) Withholdee TINc) Name of Organization or Person (Name, Father's Name and Grandfather's Name)d) Withholdee's Address*e) Withholding
Type (Rental of
Buildings/Other)		f) Taxable Amountg) Tax Withheld
((f)x2%)		h) Withholding Tax Receipt
RegionZone/
Sub-city		WoredaKebele/
Farmers Asso.		House No.NumberDate
8
9
10
11
12
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14
15
16
17
18
19
20
21
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23
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25
26
Enter Totals From Continuation Sheets Here >>
TOTAL Columns f and g
Generated by www.eGenzeb.com (As of 07/08/06) ERCA Form 1106 (1/2006)
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