|
Lampiran 1 |
||
|
Surat Edaran Direktur Jenderal Pajak |
||
|
Nomor |
: |
SE-09/PJ.10/1994 |
|
Tanggal |
: |
6 Juni 1994 |
CLAIM FOR
REFUND FROM INDONESIA 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 resident of a country
which has concluded an Avoidance of Double Tax Agreement with Indonesia, and |
|
|
(2) |
Who claims refund from
Indonesian Income Tax in respect of : |
|
|
|
(a) |
interest and/or |
|
|
(b) |
royalties 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. |
|
A1.
particulars in the form are to the properly furnished where applicable and the
declaration completed and signed. It has to be certified by the competent
authorities of the country of residence of the claimant before it is forwarded
to this District Tax Office.
|
RESIDENCE
PARTICULARS |
|||
|
A. 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
what was your last address ? |
: |
............................ |
|
(c) |
Have you retained the use of any place of residence in
Indonesia during any portion of the year 199..? |
: |
............................ |
|
|
If so, give the address and period for which it was
retained. |
: |
............................ |
|
(d) |
Have you visited Indonesia during 199..? If so, give
dates of arrival and departure |
: |
............................ |
|
(e) |
If you are a married woman, state the name and
residential address of your husband. |
: |
............................ |
|
|
|
|
|
|
B. To be completed if the claimant is a corporate or a
body of persons. |
|||
|
(a) |
Place or registration / incorporation |
: |
............................ |
|
(b) |
Place where control and management is exercised. |
: |
............................ |
|
(c) |
Address or Head Office. |
: |
............................ |
|
(d) |
Address of any branch of or office in Indonesia |
: |
............................ |
|
(e) |
Nature of business |
: |
............................ |
|
C. state the year in which income accrued |
|||
|
STATEMENT OF INCOME ACCRUED IN OR DERIVED FROM
INDONESIA |
INCOME
|
A. |
INTEREST |
: ................................ |
||
|
|
(a) |
Nature of interest : |
|
|
|
|
(b) |
Name and address of the person/agent by or through whom
payment are made : |
|
|
|
|
(c) |
Date on which interest accrued/paid : |
|
|
|
|
(d) |
Documents need to be enclosed : |
|
|
|
|
|
- |
Statement of interest payment |
|
|
|
|
- |
Notice of interest computation |
|
|
|
|
- |
Loan Agreement |
|
|
|
|
|
|
|
|
B. |
ROYALTIES |
: ................................ |
||
|
|
(a) |
Nature of royalties : |
|
|
|
|
(b) |
Name and address of the person/agent by or through whom
payment are made : |
|
|
|
|
(c) |
Date on which royalties is paid : |
|
|
|
|
(d) |
Documents need to be enclosed : |
|
|
|
|
|
- |
Contract agreement |
|
|
|
|
- |
Notice of royalty |
|
|
|
|
|
|
|
|
C. |
DIVIDEND |
: ................................ |
||
|
|
(a) |
Nature of dividend : |
|
|
|
|
(b) |
Name and address of the corporate by or through whom
payment are made : |
|
|
|
|
(c) |
Date on which dividend is paid : |
|
|
|
|
(d) |
Documents need to be enclosed : |
|
|
|
|
|
- |
Dividend declaration submitted by the payer |
|
|
|
|
- |
Statement submitted by the payer which state that
claimant is the right shareholder of the Corporate. |
|
|
|
|
|
|
|
|
D. |
RENT |
: ................................ |
||
|
|
(a) |
Nature of rent : |
|
|
|
|
(b) |
Name and address of the corporate by or through whom
payment are made : |
|
|
|
|
(c) |
Date on which rental is paid : |
|
|
|
|
(d) |
Documents need to be enclosed : |
|
|
|
|
|
- |
Contract Agreement |
|
|
|
|
- |
Rent Computation |
|
|
|
|
|
|
|
|
F. |
INCOME FROM SERVICES |
: ................................ |
||
|
|
(a) |
Name and address of payer/employer : |
|
|
|
|
(b) |
Date on which income from services is paid : |
|
|
|
|
(c) |
Documents need to be enclosed : |
|
|
|
|
|
- |
Service Contract Agreement |
|
|
|
|
- |
Statement that the recipient has no fixed place of
business in Indonesia and the services held for less than the period
mentioned on the Tax Treaty. |
|
|
|
|
|
|
|
|
G. |
BRANCH PROFIT |
: ................................ |
||
|
|
(a) |
Name and address of branch : |
|
|
|
|
|
Total income : |
|
|
D E C L A
R A T I O N
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 may be granted exemption or reduction of Indonesian Income Tax.
|
|
................................................................ |
Capacity
in which the claim is made (if the claim is made on behalf of a company or a
body person ) ................................................................
Date :
................................................................ 19 ...
rest 26.1
|
Lampiran 2 |
||
|
Surat Edaran Direktur Jenderal Pajak |
||
|
Nomor |
: |
SE-09/PJ.10/1994 |
|
Tanggal |
: |
6 Juni 1994 |
CERTIFICATION
OF COMPETENT AUTHORITIES
I/We hereby certify,
|
Name |
: |
........................................ (full name)
........................................ |
|
Address |
: |
................................................................................ |
|
in the taxable year |
: |
................................................................................ is resident taxpayer of
................................................................................ |
and
subject in the Agreement between the Republic of Indonesia and
........................................ Concerning Prevention of Fiscal
Evasion with Respect to Taxes on Income and on Capital
|
|
Signature |
............................. |
|
|
Date |
............................. |
|
|
Designation |
............................. |
|
|
Address of office |
............................. |
Official Stamp
.............................