非居民纳税人享受协定待遇信息报告表

附件AttachForm(s)非居民纳税人享受协定待遇信息报告表InformationReportingFormforNon-residentTaxpayersClaimingTreatyBenefits金额单位：人民币元（列至角分）Monetaryunit:RMBYuan(Keeptwodecimalplaces)非居民纳税人填写第1项至第17项信息，并对填报信息的真实性、准确性、合法性承担法律责任。Non-residentTaxpayersfillintheblanksofitem1to17andtakelegalresponsibilityfortheauthenticity,accuracyandlegitimacyoftheinformation.1.中文名称NameinChinese2.在中国的纳税人识别号（统一社会信用代码）TaxidentificationnumberinChina(Uniformsocialcreditcode)3.在居民国（地区）名称Nameinresidentjurisdiction4.在居民国（地区）的纳税人识别号Taxidentificationnumberinresidentjurisdiction5.在中国的联系地址、邮政编码ContactaddressandzipcodeinChina6.在中国的联系电话TelephonenumberinChina7.在居民国（地区）的联系地址、邮政编码Contactaddressandzipcodeinresidentjurisdiction8.在居民国（地区）的联系电话Telephonenumberinresidentjurisdiction9.居民国（地区）Residentjurisdiction10.电子邮箱E-mailaddress11.享受协定名称Theapplicabletreaty12.适用协定条款名称Applicablearticlesofthetreaty13.非居民纳税人是否取得缔约对方税务主管当局开具的证明非居民纳税人取得所得的当年度或上一年度税收居民身份的税收居民身份证明Whetherthenon-residenttaxpayerobtainedthetaxresidentcertificateissuedbythecompetenttaxauthorityoftheothercontractingjurisdictiontoprovetheresidencestatusofnon-residenttaxpayerfortheyearoritspreviousyearduringwhichthepaymentisreceived□是Yes□否No14.享受协定待遇所得金额Amountoftheincomewithrespecttowhichtaxtreatybenefitsareclaimed15.享受协定待遇减免税额Amountoftaxreducedorexempted16.适用股息、利息、特许权使用费条款时，非居民纳税人为“受益所有人”的政策依据是《国家税务总局关于税收协定中“受益所有人”有关问题的公告》（国家税务总局公告2018年第9号）的：□第二条；□第三条第（一）项；□第三条第（二）项；□第四条；□其他：请说明________________Ifthearticleofdividends,interestorroyaltiesisapplied,thepolicybasisfornon-residenttaxpayertobethebeneficialowneristhe□Article2;□Item1ofArticle3;□Item2ofArticle3;□Article4;□Others:Pleasespecify________________ofthePublicNoticeoftheStateTaxationAdministrationonBeneficialOwnersetforthinDoubleTaxationAgreements(PublicNotice[2018]No.9oftheStateTaxationAdministration).17.我谨声明：根据缔约对方法律法规和税收协定居民条款，我为缔约对方税收居民，相关安排和交易的主要目的不是为了获取税收协定待遇。我自行判断符合协定待遇条件，自行享受协定待遇，承担相应法律责任。我将按规定归集和留存相关资料备查，接受税务机关后续管理。Iherebydeclare:Accordingtothelaws,regulationsoftheothercontractingjurisdictionandthearticleofresidentofthetaxtreaty,Iamaresidentoftheothercontractingjurisdiction,theprincipalpurposeoftherelevantarrangementandtransactionisnottoobtaintaxtreatybenefits.Throughself-assessment,IbelievethatIaminconformitywiththeconditionsforclaimingtaxtreatybenefits,soIwillenjoytaxtreatybenefits.Therefore,Itakeduelegalresponsibilities.Iwillcollectandretainrelevantmaterialsforreviewinaccordancewiththeregulations,andacceptthefollow-upadministrationofthetaxauthority.非居民纳税人签章或签字年月日Sealorsignatureofnon-residenttaxpayerYMD以下信息不需要非居民纳税人填写Non-residenttaxpayersdonotneedtofillinthefollowingblanks18.扣缴义务人名称Nameofwithholdingagent19.扣缴义务人纳税人识别号（统一社会信用代码）：□□□□□□□□□□□□□□□□□□Taxidentificationnumberofwithholdingagent(Uniformsocialcreditcode)经办人签字：Signatureofthecasehandler：经办人身份证件号码：IDnumberofthecasehandler：扣缴义务人签章：Sealofthewithholdingagent：经办人签字：Signatureofthecasehandler：经办人身份证件号码：IDnumberofthecasehandler：代理机构签章：Sealofthetaxagent：代理机构统一社会信用代码：Uniformsocialcreditcodeofthetaxagent：受理人：Receivedby：受理税务机关（章）：Taxauthorityincharge(Seal)：受理日期：年月日Dateofcaseacceptance:YMD国家税务总局监制第1页，共1页