TATA CARA PENERAPAN PERSETUJUAN PENGHINDARAN PAJAK BERGANDA

(1)

LampiranI

Peraturan DirekturJenderal Pajak Nemer.PER-

6

1

IPJ1200g

Tanggal:

5 Nov

2009

TATA CARA PENERAPAN

PERSETUJUAN

PENGHINDARAN

PAJAK BERGANDA

A. Ketentuan

bagi Pemotong/Pemungut

Pajak

dan

Kustodian

1 .

Pemolong/Pemungul

Pajak melakukan pemolongan atau pemungulan

paja

k

alas

selia

p

penghasilan yang

dilerima

a

l

au d

iperoleh

WPLN sesuai dengan kelenluan

yang dialur

dal

am

Undang

-

Undang

Nomor 7 Tahun

198

3 l

enlang Pajak Penghasilan

sebagaimana le

lah

b

eberapa

k

ali diubah le

rakhir

d

engan

Undang-Undang

Nomor

3 6 Tahun 2008 (UU PPh

)

.

2 .

P

emolong/Pemungul

Pajak

3. P

emolong/Pe

mungul

Pajak wajib m

embual

bukli p

emolo

ngan/pemungul

an

pa

jak s

esuai d

engan

kelentuan

yang

berlaku.

Bukli

pemolongan/p

e

mungula n

pa

jak

wajib

di

sa

mpaikan

k

epada

WPLN.

4. S

ekalipun

lidak l

erdapal

pajak yang dip

olong

alau dipungul

,

Pemolong

/Pemungul Pa

jak

tetap

w

ajib

membual

bukli

p

emolong an/pemungulan

p

ajak

d

engan

m

encanl umkan

besarnya

p

enghasilan

b

rulo

,

dan m

encanlum kan "

NIHIL"

p

ada

k

olom

jumlah PPh yan

g

d

ipolong/d

ipun

gul

,

bukti pemolo ngan/p

em

ungulan

pajak d

imaks

ud

lidak waj

ib

di

sampa

ikan

k

epada

WPLN

.

5 .

P

ene

lili

an

alas SKD

(

Formulir p

ad

a L

ampiran

II

)

unluk m

emaslika

n

b

ahwa

p

enerima

p

enghasilan

bukan

S

ubjek P

ajak

d

alam

n

egeri

In

donesia

h

arus

dil

akukan

oleh P

emolong /Pemungul

P

ajak

.

Dalam hal pen

erima

p

enghasilan a

dalah

Su

biek P

ajak

dalam neg

eri

P

emolong/Pemungul Pa

jak

wajib m

emolong

atau

memung

ul

p

ajak

yang

l

e

rul

a

ng

ses

uai d

engan

k

elenluan

yang d

iatur

d

alam

UU PPh

.

Keberada

an

Subj

ek

Pajak d

a

lam

n

egeri

dilenluka n

dalam hal SKD

:

a

.

d

alam

Part IV b

utir

4 l

ercanlum a

lamal WPLN d

i I

ndonesia;

alau

b

.

dalam Part IV b

ulir 5

l

ercanlum ba

hwa

WP

LN m

empunyai

l

empal

I

inggal

l

elap

d

i Indonesia

;

alau

c

.

d

a

lam

Part

IV bulir

6 l

ercanlum

l

empa

l

k

ediaman

W

PLN

di

Indon

e

sia;

al

au

d

.

d

alam

Part

V bu

li r

1 ,

2 ,

d

an 3 me

ncanlumkan l

empal

p

endirian

,

lem

pal

k

edudukan

,

a

lau

a

lamal

ka

ntor pu

sal

WP

LN

d

i

Ind

onesia

.

6. Dalam hal per

syarala

n

admini

s

tralif

lidak dapal d

ipenu

hi

ol

e

h

WPL

N,

P

emolong/Pemungul Pa

jak

lidak

dlperkenankan m

enerapkan

k

elenluan

y

ang

dialur

d

al

am P

3B

dan wajib

memol ong al

au

m

emungul

pajak y

ang

l

e

rulang

ses

uai d

engan ke

lenluan yang d

iatur

d

a

lam

UU PPh

.

7 .

Unluk dapal m

enerapkan

P

3B ke

pada

WP

LN

,

Pemo

long/Pemungul

Pajak

m

elakukan prosedur

p

enelitian

apakah

SK

D m

encanlumkan

j

awaban

:

a

.

"

No" dalam

Bul

ir

3 Part

IV

; a

tau

b

.

"

Yes"

d

alam B

ulir 6

Pa

rt

V

;

a

la u

c

.

"

Yes"

unluk

se

luruh p

ertanyaan

da

lam B

ulir

7 sa

mpai d

engan

but

ir

1 3 Pada

P

art V

.

P3B

l

idak dile rapk

an

dalam

h

a

l

s

alah

sa

lu

j

a

w

a

b

a

n WPLN pen

erima

p

enghasilan

lid

ak ses

uai

dengan huruf

a,

b

,

al

au

c di al

as

.

8 .

D

alam

h

al

WPLN p

enerima

p

enghasilan ada

lah lemb

aga

y

ang

nam

anya dise

bulkan

seca

ra

legas

da

lam P

3B

al

au

y

ang

l

elah

di

sepakali o

leh p

ejabal ya

ng b

erwenang

d

i

Indon

esia

d

an

d

i

n

egara

milra P

3B

,

P

emol ong/Pemungul Pajak

m

enerapkan ke

lenluan yang d

latur

d

alam P3B

l

anpa

memerlukan

SKD.

9 .

P

emolong/Pemungul

P

ajak

wajib m

enyampaikan SPT

Ma

sa

d

engan

dilamp

iri

f

olokopi S

KD

dan

bu

kl

i

p

emolongan/pemungul an pa

jak

ke Kan

lo r

Pe

layanan Paj

ak

.

10 .

U

nluk p

emolongan a

lau p

emungulan

p

ajak a

las p

enghasilan

dar

i

Ir

ansaksi

p

engalihan saham

a

l

au obliga

s

i

y

ang

dip

erdagangkan a

la u

di

laporkan di

b

ursa

e

fek d

i

Indon

es

ia,

se

lain

b

unga d

an

d

ividen

,

yang dil

erima a

lau d

iperoleh WPL

N

me

lalui

K

uslodian:

a

.

F

onmulir

SKD se

bagaimana l

erdapal pa

da

La

mpiran III har

us diisi dengan lengkap dan

dilandalangani

ol

en

WPLN

p

enerima

p

enghasilan se

rta di

sahkan o

leh p

ejabal yang

b

erwena

ng

d

i

n

egara

rnt

tr

a

P

3B

;

b.

S

KD asli di

serahkan

k

epada

Ku

slodian o

leh WPLN

pe

nerima p

enghasilan

;

c

.

K

uslodian

wajib

m

enyerahkan SKD asli ya

ng

masi

h

be

rlaku y

ang

dil

erima dari WPLN kepada

Pe

molong/Pemungul

Pa

jak

;

d.

Dal

am

hal W

PLN

p

ene

rima

p

enghasilan

m

enerima

p

eng

hasilan

dar

i be

berapa

s

umber,

K

usl odian d

apat

m

embual

fo

lokopi SKD da

n m

emi

nla

l

egalisasi ke

pada

Ke

pala

Kanlor

Pe

layanan

Pajak

l

empal

Ku

slodian

l

erdaftar sebagai

W

ajib

P

aj ak

;

(2)

e

.

Kepala Kanl

or

Pelayanan Pajak yang me

legalisasi f

olokopi SKD waj

ib

menyimpan SKD asli

;

f

.

Pemo

tong/Pemungut

Pa

jak w

ajib

m

elakukan

p

emotongan a

tau p

emungutan pajak sesuai

d

engan

k

e

t

en

tu

an

yan

g

dia

tur

d

alam P3

B d

engan

m

engacu

k

epada S

KD

as

li

ya

ng m

asih

b

er

l

aku a

tau f

otokopi SK

D y

ang

t

e

l

ah d

ilegalisasi

y

ang dis

ampaikan o

leh

Kus

todian

dan

m

enyimpan

f

otokopi SKD;

g. Pemotong/Pem

ungut

Pa

jak

waj

ib

membual tanda buk

ti

pe

motongan/pemungutan

pajak serta

wa

jib m

enyerahkannya kepada WPLN mela

lui

Kustodian

.

1

1 .

Untu

k

p

emotongan a

tau

pemu

ngutan

pajak a

tas

peng

hasilan

ya

ng dit

erima atau

dip

eroleh WPLN

b

ank

:

a

.

F

ormulir

SK

D

se

bagaimana t

erdapat pada

L

ampiran

III haru

s

d

iisi

d

engan

l

engkap dan

d

itandatangani o

leh WP

LN

b

ank serta

d

isahkan o

leh

peja

bat yang b

erwenang di

n

egara mitra

P3B

;dan

b. SKD asli d

iserahkan

ke

pada

Pemotong/Pemungut Pajak

.

12 .

S

KD

waji

b d

isimpan o

leh

Pe

motong/Pemungut

Pa

jak

se

lama 10

(se

puluh) t

ahun ber

dasarkan

ke

tenluan Pa

sal

2 8 a

yat

(

11) Un

dang-Undang

Nom

or 6 Ta

hun 1

983 t

entang Ke

lenlua n

Umum

d

an Ta

ta Car

a

Perp

ajakan se

bagaimana

t

e

l

a

h

bebe

rapa

k

ali diubah l

erakhir

d

engan U

ndang

-Und

ang

Nomor

28 T

ahun 2

007 .

B

.

Pengadmi

nistrasian

SKD

oleh Kantor Pe

layanan

Pajak

1 .

Pa

da

saa

t p

enerimaan SPT

p

etugas yang menerima SPT wa

jib m

eneliti kelengka

pan

SPT Masa

P

emotong/Pemungut

Pa

jak

,

ya

ng

sek

urang-kurangnya

d

ilampiri

dengan

bukti

p

emotongan/pemungutan

p

ajak da

n f

otokopi SK

D

.

2 .

P

enelitian

k

ebenaran

p

elaporan a

tas ju

mlah pa

jak

y

ang dipoton

g a

tau dipun

gut de

ngan

m

encocokkan

f

otokopi

S

KD

denga

n

ama

WP

LN

yang

tercan

tum

da

lam

bukti

pemoto

ngan/pemungutan

pajak

,

dilakukan oleh Kepala Kan

tor

Pe

layanan

Pajak c

.q.

Kepala Seks

i

Pengawasan dan Konsultasi.

3 .

Da

lam

ha

l

Pe

motong/Pemungut

Pajak belum melaksa

nakan

kewajibannya sesuai dengan

ke

tentuan y

ang

di

atur

d

alam Pe

raturan

Direkt

ur

Je

nderal P

ajak i

ni

,

Kepa

la

Ka

ntor

Pe

layanan

P

ajak m

engi

rimk

an S

urat Himbau

an ses

uai

de

ngan

ke

tentua

n

y

a

ng

b

erlaku.

4 .

Da

lam h

al

inf

orrnasi

y

ang te

rdapat

da

lam

SKD

m

engindikasikan ke

beradaan b

entuk

u

saha tetap

dari WPLN di

I

ndonesia

,

Kan

tor

Pelayanan Pajak me

ngirimkan

i

nformasi

tersebut ke Kantor

Pelayanan Pajak yang berwenang untuk diteli

ti

kebe

radaannya

atau dibuatkan Surat Himbauan

ses

uai

de

ngan

ketentuan ya

ng

berlaku

.

5 .

P

erekaman S

KD d

an

b

ukti pemo

tongan/pemungutan

ya

ng dil

aporkan oleh Pe

motong/Pemungut

P

ajak

d

ilaksanakan

ol

eh Se

ksi P

engolahan

D

ata

I

n

f

orm

asi.

(3)

MINISTRYOF FINANCEOF THE REPUBLICOFINDONESIA DIRECTORATEGENERALOF TAXES

LampiranII

Perat uran DirekturJend era lPajak Nomor:PER·

6 1

1PJ/200g

Tangg al:

5 N

ov

2009

CERTIFICATEOFDOMICILEOFNON RESIDENT FOR INDONESIA TAX WITHHOLDING (FORM - DGT 1)

Guidance:

Thisform isto be compietedby a person(whichincludesabody ofperson,corporateor noncorporate): whois aresident ofa countrywhichhas concludeda DoubleTaxationConve ntion(OTC)with Indonesia;and

• who claims relief from Indonesia Income Tax in respect of the followi ng income earned in Indonesia (dividend. interest,

royalties, income from rendering services,and otherincome ) subject to withholding taxinIndonesia. 00not usethis form for:

a banki ngins titu tio n,or

a personwho claims relief from IndonesiaIncomeTax inrespectof incomearises from the transfer ofbonds or stocks

which traded or registered in Indonesia stockexchange and earned the income or settled the transaction through a Custodian in Indones ia, other than inte restanddividend.

All particularsin thefonn aretobeproperlyfurnished,and theform shall be signedas completed,Thisformmustbe certified bytheCompetentAuthority or hisauth ori zed rep re sentati ve inthe countrywhe re the incom erecipient is a taxpayer res ide nt before submitted toIndonesia withho ldin g agent.

Pleasenotethat thissu bm itted formmustbear the or ig inalendorsementof the Com pe te n t Auth o rity.

I

NAME OF THE COUNTRY OF INCOME RECIPIENT (I)

I

INCOME RECIPIENT: INDONESIA WITHHOLDING AGENT:

TaxJDNumber _ _ __ _ _ _ _ _ _ _(2) Tax10Number _ _ _ _ _ _ _ _ _ _ (5)

Name , (3 ) Name _ _ _ _ _ _ _ _ __ (6)

Address , (4) Address _ __ _ _ _ __ _ _ {7}

DECLARATION BY THE INCOME RECIPIENT:

I, (full name) (8) hereby declare that I have examined the

infonnation providedinthisformand tothebest of my knowledge and beliefit istrue,correct,andcomplete,1further

declarethat 0 Iam 0this com pany isnotan Indonesiaresident taxpayer.(Pleasechecktheboxaccordingly)

====

_Sig_nature_o_f_t_{he i}

= = = = = =

_ncome_r_ecipient

_or

_i_ndividual

,(9

)

authorizedtosign fortheincomerecipient

_ ' _ ' _(ID} Date(mmldd/yy)

(II)

"ea-pacrty---"'·:-O-in-wh'CC'ich:-a-cti""ng'

(12) - -cCoo;;-:-Iact-:-:CN:-um-cbe:-r

CERTIFICATION BY COMPETENT AUTHORITY OF THE COUNTRY OF RESIDENCE: For the purpose of tax relief concerning Ihe typesof income mentioned in Part V, it ishereby confinned that the

taxpay ermentioned in Part Iis a resident in (13){nameof thestate]withinthemeaning of the

Double Taxation Conve ntion in accor dance with Double Taxation Convention concluded between Indonesia and _ _ _ _ _ _ _ _ _ _,(14) [name of thestateof residence).

Date (mm' dd' yyyy):

-1_'__

(17) Officeaddress: _ __ _ __ _ _ _ _ _ _ _ _ ,(18) Official Stamp / (ifany) /

.--

/

Capacity/designallonofsignatory

__

=====..."..,=

= _

(

1 6)

=

Name

====::-::;=====~(l5}

andSignatureof!heCompetentAuthority

orhisauthorized representative

(4)

Part IV

TO BECOMPLETEDIF THEINCOMERECIPIENTIS AN INDIVIDUAL

1.Name ofIncome Recipient: (19)

2.Dateofbirth(mmlddlyyyy):

-1-1__

(20) /3.Areyou actingas anagentoranominee? 0 Yes 0 No' (21)

4.Fulladdress: _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _---'(22 )

5.Doyouhavepermanent home inIndonesia? 0 Yes 0 No') (23)

6.Inwhat countrydoyouordinarilyreside? "- (24)

7.Haveyoueverbeenresidedin Indonesia? 0 Yes 0 No') Ifso,inwhat period?

-1_'__

to

_

'-1

__

(25)

(26)

Pleaseprovide theaddress _

8.Doyouhaveanyoffice,orotherplace ofbusiness in Indonesia? 0 Yes 0 No' Ifso,pleaseprovidetheaddress

Part V

TO BE COMPLETEDIF THEINCOMERECIPIENTIS NON INDIVIDUAL

1. CountryofregistrationJincorporation: (27)

2. Which country doesthe place ofmanagement orcontrol reside? (28)

3. Addressof HeadOffice: (29)

4. Address ofbranches,offices, orotherplace ofbusinessin Indonesia (ifany): ,(30)

5. Nature of business(i.e.Pension Fund, Insurance,Headquarters, Financing) (31)

o Yes o No' o Yes o No' o Yes o No' o Yes o No' o Yes o No' (36) 10. The companyengagesin activeconductofatrade or business.

11. Theearnedincomeis SUbjecttolaxinyourcountry. (37) 12. Nomorelhan 50percentof the company'sincomeisusedto satisfy claimsbyother persons

(i.e.interest,royalties, other fees) (38)

6. The company islistedinstock market and the sharesare regularlytraded. 0 Yes 0 No ')

If yes,pleaseprovidethenameof the stockmarket: (32)

7. Thecreationofthe entityand/orthetransaction structure isnotmotivatedbyreasonstotake 0 Yes 0 No'

advantageofbenefitofthe DTC. (33)

8. Thecompanyhasits ownmanagemenl to conduct thebusinessandsuch managementhas an

independentdiscretion. (34)

9. The companyemployssufficientqualifiedpersonnel. (35)

INCOMEEARNED FROMINDONESIA IN RESPECT TO WHICH RELIEF IS CLAIMED

Thisformisavailable and maybedownloaded at thiswebsite:htto:llwNw.paiak.go.ld

*}Please checkthe appropriatebox _Thi_s_f_orm_mu_st_be_e_{ndorsed by}_t_h_e_Compe_tent_Auth_{oritie s}_:

...

~. ~. / OffICial '\ { Stamp

j

\ (ilany) j \,»<.:»:/

(5)

INSTRUCTIONS

FOR CERTIFICATEOF DOMICILE OF NON RESIDENT

FOR INDONESIA TAXWITHHOLDING (FORM- DGT 1)

Number1:

Pleasefillinthename of the country of incomerecipient.

Part I Information ofIncome Recipient: Number 2:

Please fill in the income recipient's taxpayer ldentification

number incountrywhere the claima ntisregistered as a resident

taxpayer. Number 3:

Pleasefill in the income recipient'sname. Number4:

Pleasefillinthe income recipient's address. Number5:

Please fill in the Indonesia withholding agent's taxpayer identification number.

Number6:

Pleasefillin the Indonesiawithholdingagent's name. Number7:

Please fill in theIndonesia withholdingagent'saddress. PartII Declarationbythe IncomeRecipient: Number 8:

Incase the income recipient is notan individualthis formshall

befilledbythemanagement of theincomerecipient. Pleasefill in thename of person authorized to signon behalfthe income

recipient.Ifthe income recipientis an individual,ptease fill in the

nameasstatedin Number3. Number9:

The income recipientor his representative (for non individual)

shallsign thisfonn.

Number 10:

Pleasefill in theplaceanddateofsigning.

Number11:

Please fill in the capacityof the claimant or hisrepresentative who signs thisform.

Number 12:

Pleasefillinthe contact number ofpersonwhosigns thisform. PartIII Certification by Competent Authorityof the Country of Residence:

Number 13 and 14:

Pleasefill in thenameofcountry where theincome recipientis registeredasaresident taxpayer.

Number 15 and 16

The Competent Authorities or his authorized representative shouldcertifythis fonn by signing it.The position of the signor

shoutd befilledin Number16. .

Number17:

Pleasefill in thedatewhenthefonn is signed bytheCompetent

Authoritiesorhis authorized representative. Number18:

Please fill inthe office address of the Competent Authority or authorizedrepresentative.

PartIV to be completed if the Income Recipient is an Individual:

Number 19:

Pteasefillinthe incomerecipient'sfull name. Number 20:

Pleasefillin theincomerecipient'sdateofbirth. Number21:

Pleasecheckthe appropriate box.Youareacting as anagentif

youactas anintermediaryoractfor andon behalfofother party in relationwith the income source in Indonesia. Youare ading

asanominee ifyouarethelegal owner of income orof assets

that theincomeisgenerated andyouarenot therealownerof theincomeorassets.

Number 22:

Please fillin the incomerecipient's address. Numb er23:

Pleasecheckthe appropriatebox. Ifyour pennanent home isin Indonesia,you are considered as Indonesianresident taxpayer according totheIncomeTax Law andif youreceive income from Indonesia,theDoubleTax Conventionsshallnotbe applied. Number 24:

Please fill thenameofcountry where youordinarilyreside. Number25:

Please check theappropriatebox.Incaseyou haveever been

resided in Indonesia, please fill the period of your stay and

address where you are re sided.

Number26:

Please checkthe appropriate box.Incaseyouhave anyoffices, orotherplaceof businessinIndonesia,pleasefillintheaddress of theoffices,orother place ofbusinessinIndonesia.

PartV To be Completed if the Income Recipient is non Individual:

Number27:

Please fill in the country where the entity is registered or incorporated.

Number28:

Pleasefillin thecountrywherethe entityis controlledorwhere

itsmanagementis situated. Number 29:

Please fillin Iheaddress of the entity's Head Office. Number30:

Pleasefill inthe addressof anybranches, offices,or other place of businessof the entitysituated in Indonesia.

Number31:

Pleasefill inthenature ofbusiness ofthe claimant. Number 32·38:

Please check the appropriate box in accordance with the claimant'sfactsandcircumstances.

PartVI for Income Earned from Indonesia in Respect to

whichreliefis claimed: Number39:

Please fill in the type of income (e.g. dividend, interest, or

royalties). Number40 :

Please fill in the amount of Income liable to withholding tax underIndonesianLaw.

Number41:

Please fill in the type of income from rendering services (includingprofessional).

Number42:

Please fill in the amount of income liable to withholding tax under IndonesianLaw.

Numbcr43:

Incase your incomeis arisingfromrenderingservice, pleasefill in theperiode when the service isprovided.

(6)

Number 44:

Pleasefillintheother type of income.

Number 45:

Please fill in the amount of Income liable to withholding tax

(7)

MINISTRYOF FINANCE OF THEREPUBLICOFINDONESIA

DIRECTORATE GENERAL OFTAXES

Lampiran111

PeraturanDirektur Jenderal Pajak

Nomor: PER· 61 /PJ12009

Tanggal:

5 Nov

2009

CERTIFICATE OFDOMICILEOF NON RESIDENT

FOR INDONESIA TAX WITHHOLDING (FORM - DGT 2)

Guidance:

Thisformisto becompleted by a person(whichincludes a body of person,corporate or non corporate) whoisaresidentof a

country whichhas concludedDoubleTaxationConvention(DTC)withIndonesia,who:

• isa bankinginstitution ,or

claims relieffromIndonesiaIncomeTax in respect ofincomearisesfromthetransferofbonds or stockswhichtraded or

registeredin Indonesia stock exchangeand earnedthe incomeorsettled the transactionthrough aCustodi anin Indonesia,

otherthaninterest and dividend.

All particulars in theformare tobeproperty furnishedand thefonn shallbesignedas completed.Thisfonn mustbe certified

by theCompetentAuthority orhis authorized representativein the country where the income recipient isa resident before

submitedthe Certificate to a Custodian,

Nameof theCountry of IncomeRec ipi ent: (I)

Nameofthe Inco meRecipient

Tax10number

Addre ss

_ _ _ __ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ (2)

_ _ _ _ __ _ _ __ _ _ _ __ _ _ _ __ _ _ __ _ (3)

_ __ _ _ _ __ _ _ __ _ _ _ _ _ _ _ __ _(4)

DECLARATION BY THE INCOME RECIPIENT:

1. Ideclarethat Iamaresident of (:5)[nameofthe stateofresidence!for incom etaxpurposes

withinthemeani ng of Doub le Taxatio nCo nve ntionofbothcountries;

2. In relationwith theearned income, 0 Iam 0 thiscompanyisnot actingas anagentor a nominee;(Pleasecheckthe

box accordingly)

3. The beneficial owner is not an Indonesian resid ent taxpayer and 0 I am 0 this company is not an Indonesian

resident taxpaye r;and (PleaseCheck the box accordingly)

4. Ihave exam inedthe info rm ationstatedon this fonn and 10thebe st of my knowled geand beliefitistrue, correct,

and complete;

_ _ _ _ __ _ __- -,(6)

Signatureofthe incomerecipient or

indiVidualauthorizedtosignforthe income

_ ' _1_ _(7)

Date (mmlddlyy)

; ; - ~__(8)

Capacityin whichacting _;;c-:;-

Con

tact

~-:;:-~(9)Number

CERTIFICATION BY COMPETENT AUTHORITY OF THE COUNTRY OF RESIDENCE:

For the purpose of tax relief, it is hereby confinn ed that the taxpayer mentio ned in Part I is a resident in

-".,--::-...,-,.,--::---,,----=-( IO).[nameofthe state!within themeaning oftheDouble Taxation Conve ntion in accordance

with Double Taxatio n Convention concl uded between Indonesia and (II) [name ofthe state of residence!.

Date(mmldd'yyyy):_ , _,_ _ (14)

7.'"'-~c--r--:---.,.,,---,c -__..,..,...,,..,(12) Name and Signatureof theCompetent Authonty

orhisauthorized representative

Capacity/designalOOof signatory '. ( OffICial Stamp . \ \ (danY) ,./ \.,

..

~

...

/

...

....

Officeaddress: _ _ _ _ _ __ _ _ _ __ _ _(15)

TIlistamis availableand maybedownloadedat website:hffo:llwww. oajak.qo.id

(8)

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INSTRUCTIONS

FOR CERTIFICATEOF DOMICILE OF NONRESIDENT

FORINDONESIA TAX WITHHOLDING (FORM- DGT 2)

Number 1:

Pleasefillin the nameof the country ofincomerecipient.

Number2:

Pleasefillinthename of theincomerecipient. Number 3:

Please fill in the income recipient's taxpayer identification

numberincountry wherethe income recipient is registered asa

residenttaxpayer.

Number 4:

Pleasefillin the incomerecipient's address. Number5:

This form shall be filled by the management of the claimant.

Please fill in the name of country where income recipient is

registeredasa resident taxpayer.

Number6:

Theclaimantor his representative(for non individual)shallsign this form.

Number 7:

Pleasefillin theplaceand dateofsigning.

Number8:

Please fillin the capacity of the claimant or his representative

whosignsthisform.

Numbe r9:

Pleasefill in thecontactnumber of personwhosigns thisform.

Number 10and 11:

Please fill in the name of country where the claimant is

registeredas aresidenttaxpayer.

Number12 and 13

The Competent Authorities or his authorized representative

shouldcertify thisformbysigningit. Thepositionof the signor should be filledin Number 13.

Number 14:

Pleasefillin thedate when theformissigned bythe Competent

Authorities or hisauthorizedrepresentative.

Number15:

Please fill in the office address of the Competent Authority or