Ph lc IV

T KHAI HNG HO XUT KHU - NHP KHU TI CH HQ/2010-TC

Ban hnh km theo Thng t s 194/2010/TT-BTC ngy 06/12/2010 ca B Ti chnh.
HI QUAN VIT NAM

T KHAI HNG HO XUT KHU-NHP KHU TI CH

(Bn lu Hi quan)
HQ/2010-TC

A.PHN K KHAI V TNH THU CA NGI XUT KHU, NGI NHP KHU
1.Ngi xut khu ti ch:

5. Loi hnh XK:

SXXK
GC

2.Ngi nhp khu ti ch:

8. Loi hnh NK:

SXXK
GC

6.Giy php XK:

7.Hp ng XK:

S:
Ngy:
Ngy ht hn:

S:
Ngy:
Ngy ht hn:

9.Giy php NK:

10.Hp ng NK:

S:
Ngy:
Ngy ht hn:

S:
Ngy:
Ngy ht hn:

13. Ho n
thng mi NK:
S:
Ngy:

3.Ngi ch nh giao hng:

11. a im
giao hng:

12.Ho n VAT
S:
Ngy:

4.Ngi lm th tc hi quan:

14.Phng thc

15. ng tin thanh ton:

thanh ton:
- Hng XK:
- Hng NK:

- Hng XK: .............T gi:.............

- Hng NK: .............T gi:............

S
TT

16.Tn hng
Quy cch phm cht

17.M s
hng ho

18.n
v tnh

19. Lng

Tnh thu ca ngi NK

20. n gi
nguyn t

21. Tr gi
nguyn t

1
2
3
4

S
TT

22.Thu nhp khu

Thu
sut
(%)

Tr gi tnh thu (VN)

23.Thu GTGT (hoc TTB)

Tin thu

Thu sut (%)

Tr gi tnh thu
(VN)

24.Thu khc
Tin thu

T l
(%)

S tin

1
2
3
4

Cng:
25.Tng s tin thu v thu khc ( 22+23+24): Bng s: ......................................................................................................................
Bng ch: ...........................................................................................................................................................................................
26. Chng t xut khu km theo: Bn chnh
- Hp ng thng mi:
.................
- Giy php:
..................
- Ho n VAT:
...................

Bn sao
................
..............
.............

28.Ngi xut khu ti ch: Cam kt giao ng, cc sn phm

k khai trn t khai ny v chu trch nhim v ni dung khai trn t
khai ny.
Ngy .........thng .........nm.............

27.Chng t nhp khu km theo:

- Hp ng thung mi:
- Giy php:
- Ho n thng mi:

Bn chnh
...................
....................
...................

Bn sao
...................
...................
..................

29.Ngi nhp khu ti ch: Cam kt nhn ng, cc sn phm v

chu trch nhim v ni dung k khai tnh thu trn t khai ny.
Ngy .........thng .......nm.........

(k tn, ng du, ghi r h tn)

(k tn, ng du, ghi r h tn)
B- PHN DNH CHO HI QUAN LM TH TC NHP KHU
Tng cc Hi quan
Cc Hi quan: .........................
Chi cc Hi quan: ....................

T khai s: ............./NK/........ -TC./.........

Ngy ng k: .........................................
S lng ph lc t khai: .........................

Cng chc ng k (k, ng du s hiu

cng chc)

I - Phn Hi quan kim tra thc t hng ho

30. Phn ghi kt qu kim tra ca Hi quan
Ngi quyt nh hnh thc kim tra: (k, ng du s hiu cng chc)
Hnh thc kim tra:

Min kim tra

a im kim tra:

Kim tra xc sut. T l: ..%

Kim tra ton b

Thi gian kim tra: T.. gi. , ngy

n: .gi , ngy

Kt qu kim tra: .............................................................................................................................................................................................................

...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................
............................................................................................................................................................................................................
31. i din doanh nghip nhp khu ti ch (k, ghi r h tn)

32. Cng chc kim tra thc t hng ho (k, ng du s hiu cng chc)

II- Phn Hi quan kim tra tnh thu

ST
T

33.M s hng ho

34.Lng

35.n gi

36.Tin thu nhp khu

tnh thu
Tr gi tnh thu
(VN)

Thu sut
(%)

Tin thu

1
2

S
TT

37. Tin thu GTGT (hoc TTB)

Tr gi tnh thu
(VN)

Thu
sut (%)

Tin thu

38.Thu khc
T l (%)

S tin

39. Tng s tin phi iu chnh sau khi

kim tra (Tng/Gim):
Bng s: ....................................
Bng ch:

40.Tng s thu v thu khc phi np ( 25+36): ...................................................... Bng ch :.........................................................

Thng bo thu/Bin lai thu thu s: ..........................................................Ngy................................................................................
41.L ph hi quan: ..................................................Bng ch: ..............................................................................................................
Bin lai thu l ph s: ......................................Ngy :...........................................................................................................................
42.Cng chc kim tra thu (K, 43.Ghi chp khc ca hi quan
ghi r, ngy, thng, nm, ng du
s hiu cng chc)

44. Xc nhn lm th tc hi quan (k, ng du s hiu cng

chc)

C. PHN DNH CHO HI QUAN LM TH TC XUT KHU

Tng cc Hi quan
Cc Hi quan: ...........................
Chi cc Hi quan: .....................

T khai s: ............/XK/......... -TC/...........

Ngy ng k: ..........................................
S lng ph lc t khai:.........................

Cng chc ng k (k, ng du s hiu cng chc)

45.L ph hi quan: .....................................................Bng ch : ...........................................................................................................

Bin lai thu l ph s: ..................................................Ngy:..................................................................................................................

46.Ghi chp khc ca hi quan

47.Xc nhn lm th tc hi quan (k, ng du s hiu cng chc)

PH LC T KHAI XUT KHU-NHP KHU TI CH

(Bn lu Hi quan)
Ph lc s:
Km t khai s...................../NK/...................TC/...............Ngy................. PLTKHQ/2010-TC
A. PHN K KHAI V TNH THU CA NGI XUT KHU, NGI NHP KHU
S
TT

16.Tn hng.
Quy cch phm cht

17.M s hng
ho

18. n v
tnh

19. Lng

20. n gi
nguyn t

21.Tr gi nguyn t

01
02
03
04
05
06
07
08
09
10

22.Thu nhp khu

S
TT

Thu
sut
(%)

Tr gi tnh thu
(VND)

23. Thu GTGT

(hoc thu TTB)
Tin thu

Thu sut
(%)

Tr gi tnh
thu
(VND)

24. Thu khc

Tin thu

T l (%)

S tin

01
02
03
04
05
06
07
08
09
10

Cng
28.Ngi xut khu ti ch cam kt giao ng, sn phm 29.Ngi nhp khu ti ch cam kt nhn ng, sn
k khai trn ph lc t khai ny.
phm v chu trch nhim v ni dung k khai, tnh thu trn
ph lc t khai ny.

(K tn, ng du, ghi r h tn)

(K tn, ng du, ghi r h tn)

S
TT

33.M s hng ho

34. Lng

35. n gi tnh thu

01
02
03
04
05
06
07
08
09
10

36. Tin thu nhp khu

S
TT

Tr gi tnh thu
(VND)

Thu sut
(%)

37. Tin thu GTGT (hoc

TTB)
Tin thu

Tr gi tnh thu
(VND)

Thu sut
(%)

38. Thu khc

Tin thu

01
02
03
04
05
06
07
08
09
10

42.Cn b kim tra thu (k, ghi r ngy, thng, nm, ng du s hiu cng chc)

T l
(%)

S tin