非居民納稅人享受協定待遇資訊報告表

非居民納稅人填寫第1項至第17項資訊，並對填報資訊的真實性、準確性、合法性承擔法律責任。
Non-resident Taxpayers fill in the blanks of item 1 to 17 and take legal responsibility for the authenticity, accuracy and legitimacy of the information.

1.中文名稱
Name in Chinese

2.在中國的納稅人識別號（統一社會信用代碼）
Tax identification number in China (Uniform social credit code)

3.在居民國（地區）名稱
Name in resident jurisdiction

4.在居民國（地區）的納稅人識別號
Tax identification number in resident jurisdiction

5.在中國的聯繫地址、郵遞區號
Contact address and zip code in China

6.在中國的聯繫電話
Telephone number in China

7.在居民國（地區）的聯繫地址、郵遞區號
Contact address and zip code in resident jurisdiction

8.在居民國（地區）的聯繫電話
Telephone number in resident jurisdiction

9.居民國（地區）
Resident jurisdiction

10.電子郵箱
E-mail address

11.享受協定名稱
The applicable treaty

12.適用協定條款名稱
Applicable articles of the treaty

13.非居民納稅人是否取得締約對方稅務主管當局開具的證明非居民納稅人取得所得的當年度或上一年度稅收居民身份的稅收居民身份證明
Whether the non-resident taxpayer obtained the tax resident certificate issued by the competent tax authority of the other contracting jurisdiction to prove the residence status of non-resident taxpayer for the year or its previous year during which the payment is received

 □ 是   Yes
□ 否   No

14.享受協定待遇所得金額
Amount of the income with respect to which tax treaty benefits are claimed

15.享受協定待遇減免稅額
Amount of tax reduced or exempted

16.適用股息、利息、特許權使用費條款時，非居民納稅人為“受益所有人”的政策依據是《國家稅務總局關於稅收協定中“受益所有人”有關問題的公告》（國家稅務總局公告2018年第9號）的：
□ 第二條；□ 第三條第（一）項；□ 第三條第（二）項；□第四條；□ 其他：請説明________________
If the article of dividends, interest or royalties is applied, the policy basis for non-resident taxpayer to be the "beneficial owner" is the □ Article 2; □ Item 1 of Article 3; □ Item 2 of Article 3; □ Article 4; □ Others: Please specify________________ of the Public Notice of the State Taxation Administration on "Beneficial Owner" set forth in Double Taxation Agreements (Public Notice [2018] No.9 of the State Taxation Administration).

17.我謹聲明：根據締約對方法律法規和稅收協定居民條款，我為締約對方稅收居民，相關安排和交易的主要目的不是為了獲取稅收協定待遇。我自行判斷符合協定待遇條件，自行享受協定待遇，承擔相應法律責任。我將按規定歸集和留存相關資料備查，接受稅務機關後續管理。
I hereby declare: According to the laws, regulations of the other contracting jurisdiction and the article of resident of the tax treaty, I am a resident of the other contracting jurisdiction, the principal purpose of the relevant arrangement and transaction is not to obtain tax treaty benefits. Through self-assessment, I believe that I am in conformity with the conditions for claiming tax treaty benefits, so I will enjoy tax treaty benefits. Therefore, I take due legal responsibilities. I will collect and retain relevant materials for review in accordance with the regulations, and accept the follow-up administration of the tax authority.                         

非居民納稅人簽章或簽字                                                                      年         月       日
Seal or signature of non-resident taxpayer                                                  Y         M        D

以下資訊不需要非居民納稅人填寫
Non-resident taxpayers do not need to fill in the following blanks

18.扣繳義務人名稱
Name of withholding agent

19.扣繳義務人納稅人識別號（統一社會信用代碼）： □□□□□□□□□□□□□□□□□□    
Tax identification number of withholding agent (Uniform social credit code)

經辦人簽字：
Signature of the case handler：
經辦人身份證件號碼：
ID number of the case handler：
扣繳義務人簽章：
Seal of the withholding agent：

經辦人簽字：
Signature of the case handler：
經辦人身份證件號碼：
ID number of the case handler：
代理機構簽章：
Seal of the tax agent：
代理機構統一社會信用代碼：
Uniform social credit code of the tax agent：

受理人：
Received by：
受理稅務機關（章）：
Tax authority in charge (Seal)：
受理日期：            年      月   日

Date of case acceptance:
                       Y     M      D