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1、 XX 税务局 外国居民享受避免双重征税协定待遇申请表外国居民享受避免双重征税协定待遇申请表TO XX Tax Bureau Application for Treatment Under Double Taxation Agreement一申请人事项 Details of Claimant:姓名 Full nameXXX国籍NationalityXX个人Individual住所或居所Domicile or residenceXXXXXXX邮政编码Postcode123456名称 NameXXX 公司总机构所在地Place of Head OfficeXXXX邮政编码Postcode12345
2、6实际管理机构所在地Place of effective managementXXXX邮政编码Postcode123456公司或团体Corporation or other entity注册所在地Place of registrationXXXXX邮政编码Postcode123456二所得事项 Details of Income:支付人名称 Payers nameXXX地址 AddressXXX邮编Postcode123456股息Dividends支付金额Amount of paymentXX 元支付日期Date of paymentX 年 X 月X 日支付人名称 Payers nameXXX
3、地址AddressXXX邮编Postcode123456利息Interest支付金额Amount of paymentX元合同签字日期Date of contractX 年X 月X 日合同有效期Period of contractX 年x 月x 日至 x年 x月 x日支付日期Date of paymentX年X月X日支付人名称 Payers nameXXX特许权使用费Royalties地址 AddressXXXX邮编Postcode123456支付金额Amount of paymentX元合同签字日期Date of contractX 年X 月X 日合同有效期Period of contrac
4、tX年x月x 日至x年x月x 日支付日期Date of paymentX年X月X日职业OccupationXX支付人名称Payers nameXX地址 AddressXXX邮编Postcode123456个人劳务所得Income of personalservice支付金额Amount of paymentX 元所得项目Item of incomeXX支付日期Date of paymentX年X月X日三适用的避免双重征税协定 Applicable Double Taxation Agreement:中华人民共和国同 XX 国签订的避免双重征税协定第 X 条第 X 款。Paragraph X ,
5、Article X of the Tax Agreement between the peoples 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： XX Claimant (Signature or Seal)： XX 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
6、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 theclaimant 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.Certific
7、ationWecertify that (claimants name)is a resident of according to the provision of paragraph , of A rticle in the Double Taxation Agreement between and the Peoples Republic of China.Claimants 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 t
8、ax office of China only）:编号（No.）:第 号收到申请表日期Date of receipt of application审核日期Date of examination审核意见Examination report主办人（签字）Responsible officer(signature)负责人（签字）Chief officer(signature)中华人民共和国国家税务局 主管税务机关盖章State Administration of Taxation The Peoples Republic of China Stamp of tax office关于填写外国居民享受避
9、免双重征税协定待遇申请表关于填写外国居民享受避免双重征税协定待遇申请表的说明的说明一填写范围和程序（一） 本表适用同中华人民共和国签订避免双重征税协定（以下简称税收协定）国家居民取得来源于中国的股息、利息、特许权使用费，以及个人劳务所得申请享受税收协定待遇填报。（二） 本表由受益所有人或所得取得人填写，一式两份，一并送交支付人，由支付人报送当地税务机关。当地税务机关审核认可后，退还支付人一份据以执行。二本表填写说明（一） 申请人事项：1 个人住所或居所填写申请人在税收上为其居民国家的住所或居所地址及邮政编码。2 公司或团体名称填写公司或团体的全称；总机构、实际管理机构或注册所在地，填写申请人在
10、税收上为其居民国家的总机构所在地、实际管理机构所在地或注册所在地的地址及邮政编码（二） 所得事项：个人劳务所得中的职业填写申请人为独立个人劳务或非独立个人劳务；所得项目是指工资、薪金或劳务报酬。（三） 其他事项：申请人填写对表列各项或其他需要说明的事项。（四） 未项所列主管税务机关盖章是指主管申请人提出该项税收业务的中 国县（市）级税务机关另盖本级公章。InstructionsInstructions ofof the“Applicationthe“Application forfor TreatmentTreatment underunder DoubleDouble TaxationTax
11、ation Agreement”Agreement”1Scope and procedure of filling the Form(1) THE Form is applicable to those who are residents of the countries concluded the Agreement for the Avoidence of Dou-ble Taxation (hereinafter referred to as the “Tax Agreement”)with the peoples Republic of China,and who claim for
12、treat_ments of the Tax Agreement with respect to dividends ,interest,royalties and personal services income derived from China.(2) The Form is completed by beneficial owner or income recipient in duplicate and forwarded to the payer,then submitted to the relevant local tax office by the latter.One p
13、iece of the duplicate will be returned to the payer for the enforcement upon tax offices examination and approval.2 Instructions for items in the Form(1)“Details of Claimant”i.Individuals domicile or residence,state the address of claimants domicile or residence as well as postcode in the country of
14、 claimant being a res ident for the purpose of tax.ii.Name of corporation or other rntity,give full name;Place of head office,effective management or registration,give ad-dress and postcode in the country of claimant being a resident for the purpose of tax.(2)“Details of Income”:“Occupation” in the
15、personal service income column refers to independent or dependent personal service of the claimant.“item of income”includes wages,salaries or service remuneration.(3)Others:Notes necessary by claimant on the items listed in the form or others.(4)At the close of the Form.“Stamp of tax office” means official stamp at the lrvel of tax office of the country(city)of China that is in charge of the said taxation declared by claimant.
