INCOME TAX RETURN AND SPECIAL CONTRIBUTION

It also constitutes a Refund Request for Natural Persons with Salaries, with Various Income, and Holders of F-11 V15
Companies that do not pay an installment, with a refund of up to $5,000.00

DEAR TAXPAYER, THE DECLARATION MUST BE PREPARED DECLARATION NUMBER

REPUBLIC OF EL SALVADOR
EXCLUSIVELY IN UNITED STATES DOLLARS US$
MINISTRY OF FINANCE
DIRECTORATE GENERAL OF INTERNAL REVENUE
10 111701740184 3

Exercise: Day Month Year Day Month Year ACCORDING TO TAX IDENTIFICATION CARD
From: 01 01/01/2022 9 Al: 02 31/12/2022 7 NIT: 03 1 1 0 1 - 2 6 1 2 8 7 - 1 0 1 - 9 9

First surname/Business name Second Last Name Names

I
D LUNA MEJIA DILSIA ANAI
E
N 04 Street/Avenue/Passage/Polygon/Block 05 House Number House 81 Apartment/Local
06
T San Bartolo Peaks 2 Group 51 apartment
I 07 Other data that complements the address 08 Neighborhood/Area/Residential/Distribution 09 email
[Link]@yahoo.
F
I Department/Municipality 10 Landline 77376089 11 Mobile phone Exclusive Use of the DGII
C SAN SALVADOR/TONACATEPEQUE 12 4
A Use this box only if
Mark with an X if it is excluded as Modify your Declaration
No. Declaration that Modifies
C Detail the code of the type of incentive
Passive Subject according to Art. 6 of the law of 16 7 current fiscal year. 17 5
I Income Tax
> > 18 3
Ó Use if it is a natural person and resided in the country 200
Days of Residence in the Country Detail the code of the type of Date of Death Day My Year
days or less consecutively during the Exemption from Minimum Payment
24 0 9 Settlement
N period that declares definitive
19 1 > 20 8
Taxable Income of the Fiscal Year or Period
Salaries, Wages, Bonuses, and Commissions Employee under labor subordination regime + 105 6,624.73 8
C
A Professions, Arts and Trades + 110 0.00 4
L For Service Activities + 115 0.00 5
C For Commercial Activities + 120 0.00 1
U For Industrial Activities + 125 0.00 2
L For Agricultural Activities + 130 0.00 9
O
For Profits and Dividends + 135 0.00 6
R For Goods Exports + 136 0.00 1
E For Service Exports + 138 0.00 4
N For Services Rendered Abroad and Used in El Salvador + 137 0.00 0
T
Other Taxable Income + 140 0.00 7
A
TOTAL TAXABLE INCOMES = 145 6,624.73 3
I Costs, Expenses, and Deductions of the Exercise or Period
M
P TOTAL COSTS, EXPENSES AND DEDUCTIONS = 225 1,787.02 9
O Non-Deductible Costs and Expenses (Article 29-A Income Tax Law) + 235 0.00 6
N NET INCOME (Box 145 - Box 225 + Box 235) If the result is greater than or equal to zero = 240 4,837.71 0
I
B NET LOSS (Box 145 - Box 225 + Box 235) If the result is less than zero = 242 0.00 2
L Net Income from Credits or Financing Granted Abroad (Reverse box No. 873) + 245 0.00 2
E Net Capital Gain Tax (Box No. 128 of Form F-944) + 250 0.00 7
TOTAL TAXABLE INCOME (Add Boxes 240 + 245 + 250) =255 4,837.71 3
Computed Tax on Ordinary Income 300 289.49 0
Tax Base of Net Assets (Reverse box No. 645, up to a maximum of the value determined in box No. 145 + 250 + 870) 646 0.00 7
Minimum Payment Tax (Box No. 646 x 1%) 647 0.00 4
Computed Resulting Tax (The higher value of comparing boxes No. 300 and No. 647 will be detailed) + 648 289.49 3
Net Capital Gain Tax (Box 104 of Form F-944) + 305 0.00 5
Tax on Investments in Securities and other Financial Instruments + 306 0.00 9
L Tax on Deposits in Foreign Financial Institutions + 307 0.00 6
Tax for Reduced Legal Reserve + 308 0.00 2
I
Tax on Prizes or Winnings that have not been Subject to Withholding + 309 0.00 5
Q
Tax on received profits that were not subject to withholding + 304 0.00 0
U TOTAL TAX ( Box 648 + 305 + 306 + 307 + 308 + 309 + 304) = 310 289.49 1
I Tax Withholding Accreditation for Liquidity Control according to Withholding Certificates (According to Section 7 of Article 10, Decree
Legislative No. 764/2014 - 312 0.00 3
D
Accreditation of the Excess Resulting from the Minimum Tax Payment minus the Ordinary Income Tax
A
Unused surplus from previous exercises, according to literal b), Section 2 of Art. No. 81, D.L. 762/2014 - 314 0.00 5
C Withholding Tax Creditable (Reverse Box No. 830) - 315 289.49 7
I Payment to Account - 320 0.00 8
Ó No. de Resolución 322 7 Credit according to Resolution - 325 0.00 4
N No. Declaración Ejercicio Anterior 326 2 Applicable Credit from the Previous Year - 328 0.00 5
Annual Settlement of Tax Paid in Declaration that Modifies - 329 0.00 6
Resolution No. 317 1 Decrease of balance according to Art. 74-A of the Tax Code. + 327 0.00 0
DETERMINED TAX (Box 310 - (Box 312 + 314 + 315 + 320 + 325 + 328 + 329) + 327, If the Result is Negative, Note it down between = 330 0.00 4
FINE (Mitigated according to numeral 1 of Art. 261 Tax Code) + 335 0.00 9
ANNUAL TAX SETTLEMENT (Box 330 + 335) = 340 0.00 0
Total a Devolver Renta: 345 0.00 0 Total a Pagar Renta: = 350 0.00 6
Total a Pagar Contribución Especial: = 968 0.00 7
I declare under oath that the data contained in this statement is a true expression of the truth. C.U.:QS22%4395042
I declare that I am aware that I would incur administrative and criminal penalties in the event of
breach the respective legal regulations, sanctions including those established in the
articles 249-A and 250-A of the Penal Code.

27/02/2023

Name and Signature of the Taxpayer, Legal Representative or Attorney-in-fact Signature and Seal of the Authorized Receiver Page 1/2
 COST STRUCTURE OF SALES AND INDUSTRIAL EXPENSES DEDUCTIONS FOR INDIVIDUALS
Initial Inventory of Raw Materials + 405 0.00 7 Doctors (According to Documentation) + 711 0.00 0
Cost of Items Produced/Purchased Tuition fees (According to Documentation) + 712 0.00 9
{"Importaciones/Internaciones":"Imports/Internships"} + 411 0.00 5
ISSS (Health) + 713 187.02 7
Cost of Internally Produced/Purchased Items + 412 0.00 3 Teacher Well-being + 714 0.00 5
Final Inventory of Raw Materials - 415 0.00 4 Legally permitted maximum donation (According to Documentation) + 715 0.00 3
Cost of Raw Materials Used equals 420 0.00 0 IPSFA + 716 0.00 1
Labor + 425 0.00 1 CEFAFA + 724 0.00 4
Indirect Manufacturing Costs + 430 0.00 8 AFP Voluntary Contribution (up to legal limit, Inc. 2° of Art. 22 SAP Law) + 717 0.00 0
Inventario Inicial, Producto en Proceso + 435 0.00 9 Employer Contribution Paid to the I.S.S.S. for Domestic Worker + 721 0.00 2
Final Inventory of Work in Process - 440 0.00 5 Fixed Deduction + 722 1,600.00 3
Cost of Items Produced/Purchased equals 442 0.00 6 TOTAL (Sum of box 711 to 722) = 725 1,787.02 0
Initial Finished Goods Inventory + 444 0.00 2
Final Inventory of Finished Product - 445 0.00 3
Cost of Goods Sold = 450 0.00 0
Sales Expenses Without Donation 0.00 Note: For taxpayers not required to maintain formal accounting, when filling out the boxes
+ 525 8
from 711 to 725, from 730 to 750, from 405 to 627, from 870 to 873 with the respective data, are
Administrative Expenses Without Donation + 530 0.00 4 fulfilling the obligation to present the Statement of Income and Expenditures and of
Financial Expenses Without Donation + 535 0.00 6 Balance Sheet according to Art. 91 Inc. 2 of the Tax Code.
Expenses for Minimum Payment Surplus + 538 0.00 2
Total Operating Expenses = 540 0.00 1
TOTAL COST OF GOODS SOLD AND EXPENSES OF
OPERATION (BOX 450+540)
= 545 0.00 9
Costs and Expenses of the Exercise or Period Commerce Agriculture and Livestock Services, Professions, Arts and Trades
Initial Inventory + 601 0.00 7 610 0.00 6 619 0.00 0
Cost of Produced/Purchased Items
Imports/Internations + 640 0.00 5 642 0.00 4 644 0.00 3
Cost of Items Produced/Purchased Internally + 641 0.00 9 643 0.00 8 649 0.00 5
Final Inventory - 603 0.00 3 612 0.00 2,621 0.00 1
Cost of Sales = 604 0.00 1 613 0.00 0 622 0.00 0
Sales Expenses Without Donation + 605 0.00 0 614 0.00 9,623 0.00 8
Administrative Expenses Without Donation + 606 0.00 8 615 0.00 7624 0.00 6
Expenses for Remaining Minimum Payment + 752 0.00 9 753 0.00 8 754 0.00 5
Financial Expenses Without Donation + 607 0.00 6 616 0.00 5 625 0.00 4
Operating Expenses = 608 0.00 4 617 0.00 3 626 0.00 2
Total Cost of Sales Plus Operating Expenses = 609 0.00 2 618 0.00 1,627 0.00 0
Maximum donation legally permitted, according to documentation (this box only applies to legal entities): = 650 0.00 7
Total Cost and Expenses of Industry, Commerce, Agriculture, Services, Professions, Arts, and Trades (Boxes 545+609+618+627+650) = 628 0.00 3
Legal Reserve (On Taxed Income) 215 0.00
Income from activities subject to prices Income from retail or detail sales of fuels,
controlled or regulated by the State 660 0.00 1 at authorized service stations 670 0.00 2

DETERMINATION OF THE TAX BASE OF THE NET ASSET FOR OPERATIONS FOR NON-TAXABLE INCOME OR INCOME THAT IS EXCLUDED OR THAT DOES NOT CONSTITUTE
CALCULATE THE MINIMUM PAYMENT TAX (Decree No. 762/2014)
5 RENTAL OF THE EXERCISE OR TAX PERIOD
Total Asset Value + 630 0.00 2 Non-Taxable or Exempt Income + 730 0.00 8
Depreciations and amortizations 0.00 Non-taxed exports of goods + 731 0.00 7
accumulated - 631 7
Exempt service exports + 733 0.00 5
Non-operating fixed assets - 632 0.00 8 Excluded Income or Income That Does Not Constitute Rent + 732 0.00 6
Value of shares in other companies 0.00 Non-Taxable AFP Income (Legal quota and portion of non-deductible voluntary quota), ISSS and INPEP + 734 451.98 4
Salvadorans - 633 9 Utilities and Dividends + 736 0.00 2
Non-Taxable Compensations + 738 422.00 0
Assets intended for agriculture and 0.00
livestock farming (except agro-industry) - 634 6 Costs for Non-Taxable or Exempt Rents - 740 0.00 9
Expenses for Non-Taxable or Exempt Rents - 741 0.00 7
Balance of financial obligations 0.00 Expenses for Excluded Income or that Do Not Constitute Income - 743 0.00 4
related to fixed assets that are - 635 4 Costs for Excluded Income or What Does Not Constitute Income - 742 0.00 2
in operation
Legal Reserves not Recorded or Excluded or that Do Not Constitute Income 0.00
Value of real estate received in payment 0.00 - 744 3
in payments or garnishments that are part of
- 636 1
your extraordinary assets Net Capital Gain Not Taxable (Box 148 F-944) + 746 0.00 7
Assets held abroad - 637 0.00 0 Income Obtained from Abroad, Not Subject to Tax + 869 0.00 5
Value of the technical reserves that have been 0.00 TOTAL PROFITS OF THE EXERCISE OR ASSESSMENT PERIOD 873.98
= 750 1
constituted in accordance with Standards of
- 638 3
Regulatory Authority OPERATIONS FOR LOANS, FINANCING, DEPOSITS, INVESTMENT SECURITIES
SECURITIES AND OTHER FINANCIAL INSTRUMENTS HELD ABROAD
Value of the Accounting provisions according to 0.00
Accounting technical standards authorized by the - 639 5 Income Generated Abroad + 870 0.00 6
CVCPA
Costs and Expenses for Rentals Made Abroad - 871 0.00 4
0.00 Legal Reserve for Income Earned Abroad - 872 0.00 2
TOTAL TAX BASE OF NET ASSETS
(This result affects box No.646) = 645 2
TOTAL = 873 0.00 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 who Withheld COD.
INCOME NIT of the Natural or Legal Person that Withheld Accrued Amount Monto Gravado Withholding Tax
SIMAN STORES, S.A. DE C.V. 01 0 6 1 4 - 1 7 0 2 6 6 - 0 0 1 - 3 7,076.71 6,624.73 289.49
SIMAN STORES, S.A. DE C.V. 70 0 6 1 4 - 1 7 0 2 6 6 - 0 0 1 - 3 422.00 422.00 0.00
820 6 830 3
TOTAL TAXABLE INCOME ON WHICH CREDIBLE WITHHOLDINGS WERE APPLIED 6,624.73 289.49
940 0 950 1
TOTAL TAXABLE INCOME THAT HAS BEEN SUBJECT TO FINAL WITHHOLDINGS (NON-CREDITABLE)
0.00 0.00
TOTAL OF NON-TAXABLE INCOME 943 7 TOTAL INCOME WITHOUT 945 3 947 2 949 4
TOTAL INCOME
(CODES 70, 71 AND 72) 422.00 RETENTION (CODE 60) 7,046.73 289.49
970 0
Total of differentiated taxes from boxes 304, 305, 306, 307, 308, and 309 0.00
Note: If space is insufficient, add an annex while maintaining the structure of this box.
IF YOU HAVE A REFUND: Would you like a deposit in the taxpayer's Savings Account or Checking Account? Complete the information requested below:
BANK NAME No. Count Account Type Code
920 2 925 3
EXCLUSIVE USE OF THE DGII
Company: Bank Code: 930 0
To accept the deposit on account (Same signature as on the front of this) Page 2/2