Pension Contribution Declaration Form The National Regional Government of Oromia

Federal Democratic Republic of Ethiopia Proclamation No. 715/2011

Ethiopian Revenues & (Private Organization Employees Pension Proclamation)
Bureau of Revenues
Custom Authority 
Section 1 – Taxpayer Information
3. Taxpayer Identification Number 4. Tax Account Number 8. Tax Period: Page 1 of ___
1. Taxpayer Name.(Company Name Your Name ,Father’s Name, Grandfather’s Month Year
Name

2a. 2b. Zone/K-Ketema 5. Tax Center Document Number (Official Use Only)
Region

2c. 2d. Kebele/Farmers Association 2e. House No. 6. Telephone Number 7. Fax Number
Woreda

Section 2 – Declaration Details

h) Total Amount of
f) Pension
g) Pension Contribution the
c) Employee Name(Name, Father’s d) Start Date of Employment e) Basic Contribution of Signature
a) Seq Num b) Employee TIN of Employer __% contribution __%
Name and Grandfather’s Name) (DD/MM/YY) Salary /Birr/ Employee __% I
/Birr/ /Birr/ (f + g )
/Birr/

Transfer Totals from All Continuation

Sheets to this Line >>
Total
(line 20) (line 30) (line 40) (line 50)
Section 3 – Calculation of Pension Cont. for this Period Section 4 – Employees Removed from Payroll as of this month For Official Use Only
Number of Employees on Your Payroll for this Tax Seq Employee’s Name
10 Period Employee TIN Date of Payment
Num (Name, Father’s Name, Grandfather’s Name)
Total Salary
20 (From Column e Above) Receipt Number

Total Pension Contribution of Employee (From

30 Amount of Payment
Column f Above)
Total Pension Contribution of Employer (From
40 Cheque Number
Column g Above)
Total Amount of the contribution this month
50 Cashier’s Signature
(From Column h Above)
Section 5 – Taxpayer Certification
I declare that the above declaration and all information provide here-with (including continuation sheets) is correct and Taxpayer or Authorized Employer Seal For tax Officer: Name
complete. I understand that any misrepresentation is punishable as per the tax Laws and the Penal code. Agent name _________ _____________
Signature _____________ Signature _________
Date ______________ Date ____________
The National Regional Government of Oromia Bureau of Revenue OBR Form ------ (G1/2011)
N.B. If you need more space, please use the continuation sheet
 Federal Democratic Republic
of Ethiopia Pension Contribution Declaration Form The National Regional Government of Oromia
Proclamation No.
Ethiopian 715/2011
Revenues & (Private Organization Employees Bureau of Revenues
Pension Proclamation)
Custom Authority 

Section 1 – Taxpayer Information

1. Taxpayer Name.(Company Name Your Name ,Father’s 3. Taxpayer Identification Number 8. Tax Period:
Name, Grandfather’s Name Month Year
Page 1 of ___

Section 2 – Declaration Detail

h) Total Amount
f) Pension
a)Se g) Pension of the
d) Start Date of e) Basic Contributi
q b) Employee c) Employee Name(Name, Father’s Name and Contribution contribution Signature
Employment Salary on of
Nu TIN Grandfather’s Name) of Employer __% /Birr/ (f I
(DD/MM/YY) /Birr/ Employee
m __% /Birr/ +g)
__% /Birr/

Transfer Totals
from All
Taxpayer name & Seal Continuation
Sheets to this Line
>
Total
(line 20) (line 30) (line 40) (line 50)

The National Regional Government of Oromia Bureau of Revenue (as of /5/2011) OBR Form _____ (1/2011)