外国居民享受避免双重征税协定待遇申请表
Application for Treatment Under Double Taxation Agreement
税务局
To Tax Bureau
一、申请人事项Details of Claimant：
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个人 individual |
姓名Full name |
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国籍 Nationality |
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住所或居所 Domicile or residence |
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邮政编码 Postcode |
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公司或团体Corporation or other entity |
名称Name |
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总机构所在地 |
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邮政编码 |
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Place of Head Office |
Postcode |
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实际管理机构所在地 Place of effective Management |
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邮政编码 Postcode |
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注册所在地 Place of registration |
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邮政编码 Postcode |
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二、所得事项Details of Income：
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股息 Dividends |
支付人名称 Payer’s name |
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地址Address |
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邮编Postcode |
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支付金额 Amount of payment |
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支付日期 Date of payment |
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利息 Interest |
支付人名称 Payer’s name |
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地址Address |
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邮编Postcode |
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支付金额 Amount of payment |
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支付日期 Date of payment |
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合同签字日期 Date of contract |
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合同有效期 Period of contract |
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特许权 使用费 Royalties |
支付人名称 Payer’s name |
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地址Address |
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邮编Postcode |
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支付金额 Amount of payment |
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支付日期 Period of contract |
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合同签字日期 Date of contract |
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合同有效期 Period of contract |
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个人劳 务所得 Income of personal service |
职业Profession |
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支付人名称 Payer’s name |
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地址Address |
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邮编Postcode |
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支付金额 Amount of payment |
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所得项目 Item of income |
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支付日期 Date of payment |
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三、适用的避免双重征税协定 Applicable Double Taxation Agreement：
中华人民共和国同 国签订的避免双重征税协定第 条第 款。
Paragraph ,Article of the Tax Agreement between the People’s Republic of China and .
四、声明Declaration：
我仅在此声明以上呈报事项准确无误。
I hereby declare that the above statement is correct and complete to the best of my knowledge and belief.
申请人签名或盖章：
Claimant (Signature of Seal)：
五、申请人居民身份证明（由申请人为其居民的缔约国主管税务机关填写）：或另附对方主管税务机关出具的专用证明。
Certificate of Resident Status of Claimant (For the use of responsible tax office of the Contracting state in which the claimant is a resident) or attach the special certificate of resident issued by responsible tax office of the Contracting State in which the claimant is a resident.
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Certification We certify that (claimant’s name)is a resident of according to the provision of paragraph , of Article in the Double Taxation Agreement between and the People’s Republic of China. Claimant’s serial number： Date： Signature or Stamp of tax office |
以下由中国主管税务机关填写(The following for the use of responsible tax office of China only)：
编号 （No.）：第 号
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收到申请表日期 Date of receipt of application |
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审核日期 Date of examination |
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审核意见 Examination report |
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主办人（签字） Responsible officer (Signature) |
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负责人（签字） Chief officer (Signature) |
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中华人民共和国国家税务总局
State Administration of Taxation The People’s Republic of China
