INCOME TAX AND SPECIAL CONTRIBUTION DECLARATION

It also constitutes a Refund Request for Employed Natural Persons, with Various Incomes and
F-11v15
Company leaders who do not report Payment on Account, with a refund of up to $5,000.00
STATEMENTNUMBER
REPUBLIC OF EL SALVADOR
MINISTRY OF FINANCE
DIRECTORATE GENERAL OF INTERNAL REVENUE
MR. TAXPAYER, THE DECLARATION MUST BE PREPARED EXCLUSIVELY IN
US Dollars US $
10 3

Exercise: Day Month Year Day Month Year According to Tax Identification Card
From: 01 9 Al: 02 7 NIT: 03 - - - 9

I First Last Name/Business Name or Denomination Second Surname Names

D
E 04 Street/Avenue/Passage/Polygon/Block 05 House Number 06 Apartment/ Local
N
07 Other information that complements the address 08 Neighborhood/ District/ Residential/ Allocation 09 email:
T
I
Department/Municipality 10 Telephone 11 Fax Exclusive Use of the DGII
F
12 4
I Mark with an X if excluded Detail the type of incentive code Use this box only No. Declaration that Modifies
as Passive Subject according to Art. 6 of If you modify your statement.
C 16 current fiscal year. 17 5
the Income Tax Law 18 3
A
Use if it is a natural person and resided in the Residence Days in the Detail the type code
C exemption from payment Date of Death Day Month Year
country 200 days or less consecutively Country Settlement.
I during the period you declare. definitive minimum
19 1 9 20 8
Taxable Income of the Fiscal Year or Period

C Salaries, Wages, Bonuses and Commissions (Employees under labor subordination regime) + 105 8
Á Professions, Arts and Trades + 110 4
L
For Service Activities + 115 5
C
For Commercial Activities + 120 1
U
L For Industrial Activities + 125 2
O For Agricultural Activities + 130 9
For Profits and Dividends + 135 6
R
Exports of goods + 136 1
E
For Services Rendered Abroad and Used in El Salvador + 137 0
N
T Service exports + 138 4
A Other Taxable Incomes + 140 7
TOTAL TAXABLE INCOMES = 145 3
I
Costs, Expenses, and Deductions of the Exercise or Period
M
P TOTAL COSTS, EXPENSES AND DEDUCTIONS (Box 725 + Box 628 + Box 215) - 225 9
O Costs and Non-Deductible Expenses (Article 29-A Income Tax Law) + 235 6
N
NET INCOME (Box 145 - Box 225 + Box 235) If the result is greater than or equal to zero = 240 0
I
NET LOSS (Box 145 - Box 225 + Box 235) If the result is less than zero = 242 2
B
L Net Income from Credits or Financing Granted Abroad (Reverse of box No. 873) + 245 2
E
Tax on Net Capital Gain (Box No. 128 of Form F-944) + 250 7
TOTAL TAXABLE INCOME (Sum Boxes 240 + 245 + 250) = 255 3
Computed Ordinary Income Tax 300 0
Tax base of net assets (Reverse of box No. 645, up to a maximum of the value determined in box No. 145+250+870) 646 7
Minimum Payment Tax (Box No 646 * 1%) 647 4
Computed Resulting Tax (The higher value of comparing boxes No. 300 and 647 will be detailed) + 648 3
Net Capital Gains Tax (Box No. 104 of Form F-944) + 305 5
Tax on Investments in Securities and other Financial Instruments + 306 9
Tax on Deposits in Foreign Financial Institutions + 307 6
L
Tax for reduced Legal Reserve + 308 2
I
Tax on Prizes or Winnings that Have Not Been Subject to Withholding + 309 5
Q
Tax on profits received that were not subject to withholding + 304 0
U
TOTAL IMPUESTO (Casillas 648 + 305 + 306 + 307 + 308 + 309+304) = 310 1
I
Tax Retention Accreditation for Liquidity Control according to Retention Certificates - 312 3
D
A Accreditation of the Surplus Resulting from the Minimum Payment Tax minus the Ordinary Income Tax - 314 5

C Withholding Tax Creditable (Reverse Box No. 830) - 315 7

Payment to Account - 320 8
I
Ó Resolution No. 322 7 Credit According to Resolution - 325 4

N No. Previous Year Declaration 326 2 Applicable Credit from Previous Fiscal Year - 328 5
Annual Settlement of Tax Paid in Declaration That Modifies - 329 6
Resolution No. 317 1 Decrease in balance according to Article 74-A of the C.T. + 327 0
DETERMINED TAX (Box 310 - (Box 312 + 314 + 315 + 320 + 325 + 328 + 329) + 327) = 330 4
FINE (Reduced according to numeral 1 of Article 261 of the Tax Code) + 335 9
ANNUAL TAX SETTLEMENT (Box 330 + 335) = 340 0
Total a Devolver Renta: 345 0 Total a Pagar Renta: 350 6
Total to Pay Special Contribution: 968 7
I declare under oath that the data contained in this statement is a true expression of the truth.
I declare that I am aware that I would incur administrative and criminal penalties in case of non-compliance.
respective legal regulations, penalties among which are those established in articles 249-A and 250-
 DEDUCTIONS FOR INDIVIDUALS
COST STRUCTURE OF GOODS SOLD AND INDUSTRIAL EXPENSES
7
Initial Inventory of Raw Material + 405 Doctors (According to Documentation) + 711 0
Cost of Items Produced/Purchased 5
+ 411 Tuition fees (According to Documentation) + 712 9
Imports/Internations
Cost of Internally Produced/Purchased Items + 412 3 ISSS (Health) + 713 7
4
Final Inventory of Raw Materials - 415 Teacher Welfare + 714 5
Cost of Raw Materials Used = 420 0 Legally permitted maximum donation (According to Documentation) + 715 3
1
Labor + 425 IPSFA + 716 1
Indirect Manufacturing Costs + 430 8 CEFAFA + 724 4
9
Inventario Inicial, Producto en Proceso + 435 AFP Voluntary Contribution (up to legal limit, Section 2 of Article 22 SAP Law) + 717 0
Final Inventory of Work in Process - 440 5 Employer Contribution Paid to the I.S.S.S. for Domestic Worker + 721 2
6
Cost of Produced/Purchased Items = 442 Fixed Deduction + 722 3
2 = 725 0
Initial Finished Goods Inventory + 444 TOTAL(Sum of boxes 711 to 722)
Final Inventory of Finished Products - 445 3

Cost of Goods Sold = 450 0

Sales Expenses without Donation + 525 8

Administrative Expenses excluding Donations + 530 4

Financial Expenses without Donation + 535 6

Total Gastos de Operación = 540 1

TOTAL COST OF GOODS SOLD AND EXPENSES 9

= 545
OF OPERATION (FIELDS 450 + 540)

Services, Professions, Arts and

Costs and Expenses of the Year or Period Trade Agriculture Trades
Initial Inventory + 601 7 610 6 619 0
Cost of Items Produced/Purchased + 640 5 642 4 644 3
Imports/Internationals
Cost of Items Produced/Purchased Internally + 641 9 643 8 649 5
Final Inventory - 603 3 612 2 621 1
Cost of Sales = 604 1 613 0 622 0
Selling Expenses without Donation + 605 0 614 9 623 8

Administrative Expenses without Donation + 606 8 615 7 624 6

Financial Expenses without Donation + 607 6 616 5 625 4

Operating Expenses = 608 4 617 3 626 2

Total Cost of Sales plus Operating Expenses = 609 2 618 1 627 0

Maximum legally permitted donation, according to documentation (this box applies only to legal entities) = 650 7
Total Costos y Gastos de Industria, Comercio, Agropecuaria, Servicios, Profesiones, Artes y Oficios (Casillas 545+609+618+627+650) = 628 3

Legal Reserve (On Taxable Income) 215

Income from activities subject to prices Income from retail sales.
controlled or regulated by the State
660 1
of fuels at authorized service stations
670 2

DETERMINATION OF THE TAXABLE BASE OF NET ASSETS FOR OPERATIONS FOR NON-TAXABLE INCOME OR INCOME THAT IS EXCLUDED OR NOT
5
CALCULATE THE TAX ON THE MINIMUM PAYMENT (Dec. No. 762/2015) CONSTITUTES INCOME OF THE EXERCISE OR TAX PERIOD
Valor del Activo Total + 630 2 Non-Taxable or Exempt Income + 730 8
Accumulated Depreciation and Amortization 631 7 Non-taxable exports of goods + 731 7
Non-Operational Fixed Assets 632 8 Non-taxed service exports + 733 5
Value of Shares in Other Salvadoran Companies 633 9 Excluded Income or That Do Not Constitute Income + 732 6
Assets intended for Agriculture and Livestock (Except Non-Taxable AFP Income (legal quota and portion of voluntary quota not)
Agro-industry
634 6
deductible), ISSS and INPEP
+ 734 4
Balance of Financial Obligations Related to
Fixed Assets in Operation
- 635 4 Utilities and Dividends + 736 2
Value of Real Estate Received in Payment or
Embargo that is part of its extraordinary assets.
636 1 Non-Taxable Indemnities + 738 0
Assets Held Abroad - 637 0 Costs for Non-Taxable or Exempt Rents - 740 9
Value of the Technical Reserves that have been Established
according to the regulations of the regulatory entity 638 3 Expenses for Non-Taxable or Exempt Rents - 741 7
Value of Accounting Provisions according to standards
639 5 Costs for Excluded Income or What Does Not Constitute Income - 742 2
accounting techniques authorized by the CVCPA
TOTAL TAXABLE BASE OF NET ASSET
(This result affects box No. 646)
= 645 2 Expenses for Excluded Income or Income That Does Not Constitute Revenue - 743 4
OPERATIONS FOR CREDITS, FINANCINGS, DEPOSITS,
INVESTMENTS IN SECURITIES AND OTHER INSTRUMENTS Non-taxable or excluded legal reserve that does not constitute income - 744 3
FINANCIALS CARRIED OUT ABROAD
Income Obtained Abroad + 870 6 Net Capital Gains Not Taxable (Box No. 148 F-944) + 746 7

Costs and Expenses for Rents Made Abroad - 871 4 Income Obtained from Abroad, Not Subject to Tax + 869 5
Legal Reserve for Income Earned Abroad - 872 2
TOTAL INCOME FOR THE FINANCIAL YEAR OR TAXATION PERIOD = 750 1
TOTAL = 873 0

Salaries, wages, compensations, taxable bonuses, executive lawsuits, and other withheld taxes
805 2 810 1 821 9 815 0 825 7
Name of the Natural or Legal Person
what retained Code Tax
NIT of the Natural or Legal Person who Withheld Accrued Amount Taxable Amount
Income Held
- - -
- - -
- - -
820 6 830 3
TOTAL TAXABLE INCOME ON WHICH CREDIBLE WITHHOLDINGS WERE MADE
0.00 0.00
940 0 950 1
TOTAL TAXABLE INCOME SUBJECT TO FINAL WITHHOLDINGS (NON-CREDITABLE) 0.00 0.00
TOTAL OF NON-REVENUES 943 7 TOTAL INCOME WITHOUT 945 3 TOTAL, OF 947 2 949 4
RECORDED (CODES 70, 71 AND 72) RETENTION (CODE 60) INCOME
Total of Differentiated Taxes from boxes 304, 305, 306, 307, 308, and 309. 970 0
 INCOME TAX AND SPECIAL CONTRIBUTION DECLARATION
It also constitutes a Refund Request for Employed Individuals with Diverse Incomes and
F-11v15
Company headlines that do not collect payment on account, with a refund of up to $5,000.00
STATEMENTNUMBER
REPUBLIC OF EL SALVADOR
MINISTRY OF FINANCE
GENERAL DIRECTORATE OF INTERNAL REVENUE
MR. TAXPAYER, THE DECLARATION MUST BE PREPARED EXCLUSIVELY IN
United States Dollars US $
10 3

DETAIL OF DONATIONS MADE IN THE PERIOD OR EXERCISE

Name of the Institution NIT of the Institution Value of the Donation
905 - - - 9 910 5
905 - - - 9 910 5
905 - - - 9 910 5
TOTAL 917 1

DECLARATION AND PAYMENT OF THE SPECIAL CONTRIBUTION FOR LARGE CONTRIBUTORS FOR THE
CITIZEN SECURITY PLAN

Net Rent + 240

Net Income from 01-01 to 05-07 of 2019 (C240) + 972

Tax on Net Capital Gain + 250

Capital Gains Tax from 01-01 to 05-07 of 2019 (C250) + 974

Tax on Net Capital Gain (Box No. 104 of Form F-944) + 975

Income from Investments in Securities and Other Financial Instruments + 976

Rent for Deposits in Foreign Financial Institutions + 977

Reduced rental for legal reserve + 978

Rent for Prizes or Earnings that have not been Subject to Withholding + 979

Income from received utilities that were not subject to withholding + 981

Net Taxable Income for the purposes of the Special Contribution for Large Taxpayers = 952

Net Taxable Income for the purposes of the Special Contribution for Large Taxpayers from 01-01 to 05-07
=
from 2019
Computed Tax on the Net Taxable Income for the purposes of the Special Contribution for the Large - 954
Taxpayers

Utilities of the Exercise or Tax Period for Non-Taxable Income Operations or Income that are + 955
Excluded or those that do not constitute Income of the Year except for Income Obtained Abroad
Utilities and Dividends that have already been subject to the payment of the Special Contribution for Major Taxpayers - 956

Use of the Exercise or Assessment Period for Transactions on Non-Taxable Income or Excluded Income - 958
that do not constitute income from operations abroad
Net Profit for the Period = 960

Net Profit of the Fiscal Year Subject to Special Contribution Applies only for the Fiscal Years 2015 and 2020 = 962

Calculation of Special Contribution = 964

Special Contribution Paid in Statement that Modifies - 966

Total to Pay Special Contribution = 968

UTILITIES AND DIVIDENDS THAT HAVE ALREADY BEEN SUBJECT TO THE SPECIAL CONTRIBUTION PAYMENT
THE LARGE TAXPAYERS
No. Corporate Name or Denomination NIT Exercise
1 850 7,852 8

2 850 7,852 8

3 850 7 852 8

DETAIL OF FINANCIAL ENTITIES FOR THE ACCREDITATION OF TAX WITHHOLDING

LIQUIDITY CONTROL
No. 982 Bank or Financial Institution Name 980 NIT of Bank or Entity 984 Exercise 986 Amount Retained
1
2
Total: 0.00