Lampiran I

Surat Edaran Direktur Jenderal Pajak

Nomor

:

SE-22/PJ.35/1993

Tanggal  

:

31 Agustus 1993

 

 

CLAIM FOR RELIEF FROM INDONESIAN INCOME

TAX UNDER AVOIDANCE OF DOUBLE TAXATION AGREEMENT

 

This form is to be completed by a person (which includes a body of persons, corporate or not corporate)

(1)

who is a resident of a country which has concluded an Avoidance of Double Taxation Agreement with Indonesia, and

(2)

who claims relief from Indonesian Income Tax in respect of :

 

(a)

interest and/or

 

(b)

royaltieds and/or

 

(c)

dividend and/or

 

(d)

rent and/or

 

(e)

income from services and/or

 

( f )

branch profit 

 

        accrued in or derived from Indonesia for the year ............... or from date ...................................... 19 ......... to date  ...................................... 19 ......... *)

 

        All particulars in the from are to the properly furnished where applicable and the declaration completed and signed.

 

RESIDENCE PARTICULARE

1.

To be completed if the claimant is an individual

 

 

(a)

In what country do you ordinarily reside?

...........................................................................

 

(b)

Have you ever been resident in Indonesia ?
If so, when were you so resident, for what period and waht was your last address?

...........................................................................
  
   

 

(c)

Have you visited Indonesia during 19 ...........?
If so, give dates of arrival and departure.

...........................................................................
  

 

(d)

If you are a married woman, state the name and residential address of your husband.

...........................................................................
  

2.

To be completed if the claimant is a corporate or a body of persons

 

(a)

Place of registration/incorporation ?

...........................................................................

 

(b)

Place where control and management i s exercised ?

...........................................................................

 

(c)

Address of Head Office ?

...........................................................................

 

(d)

Address of any branch of or office in Indonesia ?

...........................................................................

 

(e)

Nature of business ?

...........................................................................

KP.PPh.3.49

 

 

 

STATEMENT OF INCOME ACCRUED IN OR

DERIVED FROM INDONESIA

 

A.

INTERENST

(a)

Nature of interest :

(b)

Name and address of the person/agent by whom payment are made :
...............................................................................................................................................................................
...............................................................................................................................................................................

(c)

Based on Contract/Agreement **) ............................................................................................................................
...............................................................................................................................................................................

 

B.

ROYALTIES

(a)

Nature of royalties : .................................................................................................................................................
...............................................................................................................................................................................

(b)

Name and addres of the person/agent by whom payment are made : ........................................................................ ............................................................................................................................................................................... ...............................................................................................................................................................................

(c)

Based on Contract/Agreement **) ............................................................................................................................ ...............................................................................................................................................................................

    

C.

DIVIDED

(a)

Nature of dividend : ................................................................................................................................................. ...............................................................................................................................................................................

(b)

Name and address of the corporate by whom payment are made :
............................................................................................................................................................................... ............................................................................................................................................................................... ...............................................................................................................................................................................

 

D.

RENT

(a)

Nature of rent : ........................................................................................................................................................ ...............................................................................................................................................................................

(b)

Name and address of the corporate by whom payment are made : ............................................................................................................................................................................... ...............................................................................................................................................................................

(c)

Based on Contract/Agreement **) ............................................................................................................................ ...............................................................................................................................................................................

 

E.

INCOME FROM SERVICES

(a)

Name and address of payer/employer : ................................................................................................................... ...............................................................................................................................................................................

(b)

Based on Contract/Agreement **) ............................................................................................................................ ............................................................................................................................................................................... ...............................................................................................................................................................................

 

F.

BRANC PROFIT

(a)

Name and address of branch : ................................................................................................................................. ............................................................................................................................................................................... ............................................................................................................................................................................... ...............................................................................................................................................................................

 

*)

State the date, month and year in which income accrued

**)

State the name, number and year of contract

   

DECLARATION

  

I (full name) ......................................................................................................................................... hereby declare

(1)

that this form is completed on my own behalf/on behalf of

......................................................................................... ............................................................................................................................................................................... residing at .............................................................................................................................................................. ...............................................................................................................................................................................
 

(2)

that all particulars furnished on this form are to the best of my knowledge and belief true and correct in every respect  and claim on my own behalf/on behalf of

............................................................................................................... ............................................................................................................................................................................... ...............................................................................................................................................................................
 

that the income as furnished above my be granted exemption or reduction of Indonesian Income Tax.

 

.......................................................................... Signature of person (individual) making the claim.

 

Capacity in which the claim is made (if the claim is made on behalf of a company or a body of person) ................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................

 

 

Date ................................................................... 19.......

 

 

 

Lampiran II

         

FORMULIR PEMBEBASAN ATAU PENGURANGAN TARIF

PPh PASAL 26 DALAM RANGKA PERSETUJUAN

PENGHINDARAN PAJAK BERGANDA

(OLEH PEMOTONG)

   

Formulir ini harus diisi oleh orang atau badan :

Yang terutang/membayar penghasilan kepada orang atau badan yang berdomisili di Negara yang telah berlaku Persetujuan Penghindaran Pajak Berganda dengan Indonesia.

 

Jenis penghasilan yang dibayarkan atau yang terutang berupa :

(a)

bunga dan/atau

(b)

royalti dan/atau

(c)

dividen dan/atau

(d)

sewa dan/atau

(e)

imbalan atas jasa

 

pada tahun  ........... atau dari tanggal ...................................... 19 ......... sampai dengan tanggal  ...................................... 19 ......... *)

 

IDENTITAS PENERIMA PENGHASILAN

1.

Diisi jika penerima penghasilan adalah perorangan

 

1.

Nama Wajib Pajak penerima penghasilan

...........................................................................

 

2.

Negara dimana yang bersangkutan merupakan Wajib Pajak dalam negeri

...........................................................................
  

 

3.

Alamat penerima penghasilan di negara yang bersangkutan terdaftar sebagai Wajib Pajak dalam negeri.

...........................................................................
  

2.

Diisi jika penerima penghasilan adalah badan

 

1.

Nama Badan penerima penghasilan

...........................................................................

 

2.

Negara di mana yang bersangkutan merupakan Wajib Pajak dalam negeri

...........................................................................
 

 

3.

Alamat penerima penghasilan

...........................................................................

 

4.

Alamat cabang apabila penerima pembayaran adalah cabang dari perusahaan tersebut pada butir 1

...........................................................................
 

Harus dicantumkan berikut tanggal dan tahun.

 

KP.PPh.3.50

  

JENIS PENGHASILAN YANG DIBAYARKAN ATAU TERUTANG

  

A.

BUNGA

(a)

Jenis bunga : .................................................................................................................... (bunga pinjaman, bunga obligasi, bunga deposito dsb.)

(b)

Kontrak yang mendasari **) .....................................................................................................................................
............................................................................................................................................................................... ...............................................................................................................................................................................
 

B.

ROYALTI

(a)

Royalti sehubungan dengan : .................................................................................................................................. (penggunaan hak merk dagang, informasi dsb) ........................................................................................................ ...............................................................................................................................................................................
...............................................................................................................................................................................

(b)

Kontrak yang mendasari **) .....................................................................................................................................
............................................................................................................................................................................... ...............................................................................................................................................................................
  

C.

DIVIDEN

(a)

Dividen berasal dari : .............................................................................................................................................. ...............................................................................................................................................................................

(b)

Perjanjian yang mendasari bahwa dividen dibayar netto **) ....................................................................................... ............................................................................................................................................................................... ...............................................................................................................................................................................

 

D.

SEWA

(a)

Sewa atas : ............................................................................................................................................................. ...............................................................................................................................................................................

(b)

Kontrak yang mendasari **) .....................................................................................................................................
............................................................................................................................................................................... ...............................................................................................................................................................................
  

E.

PEMBAYARAN ATAS JASA

(a)

Jenis Jasa : ............................................................................................................................................................ ...............................................................................................................................................................................

(b)

Kontrak yang mendasari **) .....................................................................................................................................
............................................................................................................................................................................... ...............................................................................................................................................................................
  

 **) Cantumkan nama, tahun dan nomor kontrak.

 

 

 

SURAT PERNYATAAN

  

Saya (nama lengkap)  ......................................................................................................................................... dengan ini menyatakan :

(1)

bahwa formulir ini telah diisi atas nama saya/atas nama ...

......................................................................................... ............................................................................................................................................................................... beralamat di ............................................................................................................................................................ ...............................................................................................................................................................................
 

(2)

bahwa seluruh informasi yang kami nyatakan dalam formulir ini adalah benar-benar tanpa syarat, atas nama saya sendiri/atas nama ................................................................................................................................................... ...............................................................................................................................................................................
 

 

mengajukan permohonan agar atas penghasilan yang terutang atau dibayarkan, dibebaskan atua dikurangkan tarifnya sesuai dengan Persetujuan Penghindaran Pajak Berganda RI dengan negara ................................................................................

 

 

Tanda tangan pemohon apabila permohonan adalah atas namanya sendiri .......................................................................... ........................................................................................................................................................................................

   

 

Tanda tangan yang mewakili pemohon jika pemohon atas nama badan  ............................................................................. ........................................................................................................................................................................................  

 

Date ................................................................... 19.......

  

 

   

 

DEPARTEMEN KEUANGAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PAJAK
KANTOR PELAYANAN PAJAK ...............................

____________________________________________

Lampiran III
Surat Edaran Dirjen Pajak

Nomor

:

SE-22/PJ.35/1993

Tanggal

:

31 Agustus 1993

 

 

 

 

Lembar 1

untuk Wajib Pajak;

 

Lembar 2

untuk Pemotong Pajak;

 

Lembar 3

untuk Kakanwil DJP;

 

Lembar 4

untuk Dit. PP;

 

Lembar 5

untuk arsip KPP.

 

 

                              Kepada Yth. :

 

Nama Pemotong

:

..............................................................

 

NPWP

:

..............................................................

 

Alamat

:

..............................................................

    

SURAT KETERANGAN BEBAS PPh PASAL 26

Nomor :                                                          

 

Kepala Kantor Pelayanan Pajak ................................................................................ menerangkan bahwa orang pribadi/ badan tersebut di bawah ini :

 

Nama

:

............................................................................................................................................................

Alamat

:

............................................................................................................................................................

Negara tempat berdomisili/berkedudukan : ..................................................................................................................

  

dibebaskan dari pemotongan PPh Pasal 26 sesuai dengan Persetujuan Penghindaran Pajak Berganda (P3B) dengan perincian sebagai berikut :

 

JENIS
PENGHASILAN

DASAR HUKUM *)

M A S A

KONTRAK ATAU DOKUMEN LAIN YANG MENDASARI **)

KETERANGAN

 

 

 

 

 

 

 

 

 

 

Berlaku sepanjang Wajib Pajak yang bersangkutan berdomisili di negara sebagaimana yang tercantum pada Surat Keterangan ini.

 

 

 

 

....................................., ...........................

 

KEPALA KANTOR PELAYANAN PAJAK

............................................................

 

 

...........................................................

NIP.                                                   

*) 

Diisi Pasal dari P3B yang bersangkutan.

**) 

Cantumkan nama, tahun dan nomor kontrak atau dokumen lain yang mendasari terutangnya/dibayarnya penghasilan yang bersangkutan.

KP. PPh. 3.52

 

 

 

 

DEPARTEMEN KEUANGAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PAJAK
KANTOR PELAYANAN PAJAK ...............................

____________________________________________

Lampiran IV
Surat Edaran Dirjen Pajak

Nomor

:

SE-22/PJ.35/1993

Tanggal

:

31 Agustus 1993

 

 

 

 

Lembar 1

untuk Wajib Pajak;

 

Lembar 2

untuk Pemotong Pajak;

 

Lembar 3

untuk Kanwil Wilayah Ditjen Pajak;

 

Lembar 4

untuk Direktorat Peraturan Perpajakan;

 

Lembar 5

untuk arsip Kantor Pelayanan Pajak.

 

 

                              Kepada Yth. :

 

Nama Pemotong

:

..............................................................

 

NPWP

:

..............................................................

 

Alamat

:

..............................................................

 

   

SURAT KETERANGAN TARIF PPh PASAL 26

Nomor :                                                          

 

Kepala Kantor Pelayanan Pajak ................................................................................ menerangkan bahwa orang pribadi/ badan tersebut di bawah ini :

 

Nama

:

............................................................................................................................................................

Alamat

:

............................................................................................................................................................

Negara tempat berdomisili/berkedudukan : ..................................................................................................................

 

 

............................................................................................................................................................

  

dikenakan pemotongan PPh Pasal 26 dengan tarif sesuai Persetujuan Penghindaran Pajak Berganda (P3B) RI - ............................................... dengan perincian sebagai berikut :

 

JENIS
PENGHASILAN

DASAR HUKUM *)

M A S A

TARIF PPh
MENURUT
P3B

KONTRAK ATAU DOKUMEN LAIN YANG MENDASARI **)

KETERANGAN

 

 

 

 

 

 

 

 

 

 

Berlaku sepanjang Wajib Pajak yang bersangkutan berdomisili di negara sebagaimana yang tercantum pada Surat Keterangan ini.

 

 

 

 

....................................., ...........................

 

KEPALA KANTOR PELAYANAN PAJAK

............................................................

 

 

...........................................................

NIP.                                                   

*) 

Diisi Pasal dari P3B yang bersangkutan.

**) 

Cantumkan nama, tahun dan nomor kontrak atau dokumen lain yang mendasari terutangnya/dibayarnya penghasilan yang bersangkutan.

KP. PPh. 3.53

 

 

 

 

DEPARTEMEN KEUANGAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PAJAK
KANTOR PELAYANAN PAJAK ...............................

____________________________________________

Lampiran V
Surat Edaran Dirjen Pajak

Nomor

:

SE-22/PJ.35/1993

Tanggal

:

31 Agustus 1993

 

 

 

 

Lembar 1

untuk Wajib Pajak;

 

Lembar 2

untuk Pemotong Pajak;

 

Lembar 3

untuk Kanwil Wilayah Ditjen Pajak;

 

Lembar 4

untuk Direktorat Peraturan Perpajakan;

 

Lembar 5

untuk arsip Kantor Pelayanan Pajak.

 

 

 

                              Kepada Yth. :

 

Nama Pemotong

:

..............................................................

 

NPWP

:

..............................................................

 

Alamat

:

..............................................................

  

SURAT PENOLAKAN PERMOHONAN BEBAS/PENGURANGAN TARIF PPh PASAL 26 *)

Nomor :                                                          

 

Kepala Kantor Pelayanan Pajak ................................................................................ menerangkan bahwa Permohonan Bebas/Pengurangan Tarif *) PPh Pasal 26 orang pribadi/badan tersebut di bawah ini :

 

Nama

:

............................................................................................................................................................

Alamat

:

............................................................................................................................................................

Negara tempat berdomisili/berkedudukan : ..................................................................................................................

 

 

............................................................................................................................................................

ditolak, karena :

 

   

 

 

 

 

....................................., ...........................

 

KEPALA KANTOR PELAYANAN PAJAK

............................................................

 

 

...........................................................

NIP.                                                   

*) 

Coret yang tidak perlu.

KP. PPh. 3.54

 

 

 

 

 

Lampiran VI

Surat Edaran Direktur Jenderal Pajak

Nomor

:

SE-22/PJ.35/1993

Tanggal  

:

31 Agustus 1993

 

DAFTAR SKB/SKT PPH PASAL 26

(Sebagai Lampiran SPT PPh Pasal 26)

 

NO.

NOMOR DAN TANGGAL
SKB / SKT

NAMA WAJIB PAJAK
PENERIMA PENGHASILAN

ALAMAT DAN NEGARA
DOMISILI

KETERANGAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jakarta, ................................ 19 ..........

 

Pemotong PPh Pasal 26

 

 

________________________

KP. PPh. 3.55