(Address)..................
...................................
...................................
Tel :..........................
Fax :.........................
................... , 20.......

Description of Income

Taxpayer name and address

Amount of gross income

Amount of tax paid and date of payment

Taxable year

Relevant provisions of law

            I hereby certify that the amount of tax shown above has been paid to the Revenue Department of Thailand. This certificate is issued upon the request of the above taxpayer for whichever legal purpose it may serve.