Peraturan Direkt Jena Palak MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA Nomor PER. 8172008 DIRECTORATE GENERAL OF TAXES ‘Tanggat § November 2000, CERTIFICATE OF DOMICILE OF NON RESIDENT FOR INDONESIA TAX WITHHOLDING (FORM - DGT 1) Guidance: Tis form isto be completed by a person (which incudes a bedy af person, corporate or non corporat): + who i a resident ofa courtry which has concluded a Double Taxation Converion (OTC) with Indonesia: and + wi claims reli from Indonesia Income Tax in respect of the follwing income earned in Indonesia (cvidend, interest, Toya, Income from rendenng services, and ather income) subject to withnolding tax n indonesia, oot use this form for: + @ banking institution, or +2 prson who claims rai from Indonesia Income Tax in respect of income arises from the transfer of bonds or stocks ‘whic taded or reuistred in Indonesia stock exctane and waned the income or selled the tarsacton Urougt Custodian in indonesia, othe than interest and dividend ‘All particulars inthe form are tobe property furnished, andthe form shall be signed as completed. This form must be cetiied by the Competent Authority or his authorized representative or authorized tax office in the Country where the income recipient |S taxpayer resident before submited to Indonesia wihholding agent. NAME OF THE COUNTRY OF INCOME RECIPIENT = © GEREN 'NCOME RECIPIENT: INDONESIA WITHHOLDING AGENT: Taxi Number @)] Taxin Number ° Name co] Name 6 Address | Address ‘ 0 FERRI oct aration ev THe income RECIPIENT: 1, full name (8) hereby declare that | have examined the information provided inthis form and tothe best of mv knowledae and belie itis tre. correct. and comolete.| further declare that cl am < this company isnot an Indonesia resident taxpayer. (lease ces ib box arcosingy) “Soraie obama par er ro ire ene wpe oh Dabinniély)” Capac ached” Coa amber authorized to sign for te mcome recipient L a sa ™ ‘CERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF THE COUNTRY OF RESIDENCE: For the ouroose of tax relief. it fs hereby confirmed that the taxoaver mentioned in Part | is a resident in {13am oft ete within the meanina_of the Double Taxation Convention in accordance vith Double Taxation Convention concluded between Indonesia and (1) nae ft at of nest Date (riyyy): Ian) — iy orc! NivwaniSmraue da Comaettaboiy oie | Sane uthoraedrereseniatve or suborzedtaxoice oftew address 0) as) Capaniiseagatin et saraany This foro avalble and may bo downibaded at thie wobote isi peat go Thi ces evar 12 vee) monte comming am the dt eston Page 1FERRI 10-5 compete iF THE INCOME RECIPIENT IS AN INDIVIDUAL 2. ate ofthe: Jam | 8 Ae youactna a an opetor anomie? Yes o No” ch 5 Do you have permanent home in Indonesia? Yes Na? Ox) 6. Inwhat county do vou ordinarily reside? on 7 Have you aver haen rested in ineonesia? Yes Nn? fen inwhat paring? Please orovide the address. Da you have any office, or other place of husinassin Indonesia? Yes > No” 06) a9, If's0, please provide the address. JEREMY 10.5 compteteo ir THE INCOME RECIPIENT IS NON INDIVIDUAL zi County of regstrationincorporation: an Which counisy does the place of management or control reside? es) Address of Head Ofc: 09) 4. Address of branches, offices, or other pace of business in Indonesia if any): 0 5. Nature of business (Le, Pension Fund, Insurance, Headquarters, Financina) oD 6. The company is listed in stock market and the shares are reaulary traded 3 Yes © NO” It yes, please provide the name of the stock market oa 7. The creation ofthe entty andlor the transaction structure is not motivated by reasons to take = Yes c No” advantage of benefit ofthe DTC. on 8. The company hae ite own management to conduct the bueineee and euch management hae ano Yes c No” independent giscetion Ga Tha company employs sufisent qualified personnal 5 8 Yes © No? 10, The company engages in active conduct ofa trad or business (m9 Yes © No? 11. The earned income is subiect to tax in your country. on 0 Yes o No? 12, No more than 50 per cent of the company's income is used to satisfy caims by other persons Yes 0 No? (ie. interest, royale, other fees) 68) [ERENT come canned FROM INDONESIA IN RESPECT TO WHICH RELIEF IS CLAIMED 1. Dividend, Interest, or Royalties a. Type of Income: 69, hh Amount af Ineame aha t withholding tay undae Indonesian | awe IDR. my 2. Income from rendering services (including professional) 8, Type of Incomes: wp b. Amount of Income liahle fo withholding tax under Indonesian Law- IDR @ ©. Period of engagement (mmddyy): 43) Prom: | f to td PFom / Jt J 1 Feo From _s 3. Other Type of Income: 8, Type of incomes: ae) b. Amount of Income liahle to withholding tax under Indonesian Law- IDR. “s) This form's avaleie and may be dourinaded et his webste in nw Asien aa "TP check the appropriate bax | declare that | have examined the information provided inthis form and to the best of my knowledge and belie itis true, correct, and complete. oe ry — Sgt die neone reaped vay Capac ini a Taree mbar ‘uoraed 691 tbe reanerecpat ae a]INSTRUCTIONS FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR INDONESIA TAX WITHHOLDING (FORM — DGT 1) Number 4 Please fil n the name of the county of income recipient. Part! Information of income Recipient: Number 2: Please fil in the income recipient's taxpayer identification fhumber in county where te claimant s registered as a resident taxpayer Number 3; Please fil n the income recipien’'s name. Number 4: Please fill in the income recipian’s address. Number 5: Please fil in the Indonesia withholding agent's taxpayer Identifeaion number Number 6: Please fil n the Indonesia withholding agents name. Number 7: Please fill in the Indonesia withholding agents address, Ft l_Declaration by the Income Recipient Number 8: Incase the income recipient is not an individual this form shall bo filed by the management of the income recipiont. Please il in the name of person authorized to sign an behalf the income recipient. I the income recipient is an inavidual please fil inthe ‘name as stated in Number 8 Number 9 The income recipient or his representative (for non individual) shall sign this form, Number 10: Please filn the place and date of signing. Number 11 Please fil in tho capacity of the claimant or his representative who signs tis form. Number 12: Please fll in the contact number of person who sighs this form. Part l_Certification by Competent Authority or Authorized ‘Tax Office of the Country of Residence: Number 13 and 14: Please fil in the name of country where the income reciplnt is fegistored as a resident taxpayer. Number 15 and 16 The Competent Authorties or his authorized representative or authorized tax offce should cerity this form by signing it The positon ofthe signor should be files in Number 16, Number 17: Please fil in the date when the form is signed by the Competent ‘Authorities. or his authorized representative or authorized tax office Number 18 Please fil in the office address of the Competent Authority or authorized representative or authorized tax offic. PartiV to be completed if the Income Recipient is an ingividual: Number 19: Please fli the Income recipient full name. Number 20: Please film the income recipiont's dato of birth Number 21: Please check the appropriate box. You are acting as an agent if you act as an inlermediary or act for and on behalf of other party in relation with the income source in Indonesia. You are acting as a nominee i you are tne legal owner of income or of assets that the income is generated and you are not the real owner of the income or assets, Number 22: Please fil in the income recipient's adcress. Number 23: Please check the appropriate box. If your permanent home isin Indonesia, you are considered as Indonesian resident taxpayer ‘according othe Income Tax Law and ifyou receive income from Indonesia, the Double Tax Conventions shal nat be applied Number 24: Please file name of county where you ordinary reside Number 25: Please check the appropriate box. In case you have ever been resided in indonesia, please fil the period of your slay and address where you are resided Number 26: Piease check the appropriate box. In case you have any fees, ‘or oer place of business in Indonesia, pleas fil inthe address ‘ofthe offices, or other place of businass in Indonesia, PartV_To be Completed if the Income Recipient is non individual: Number 27 Piease fll in the country where the ently is registered or incorporated. Number 28: Piease filn the country where the ently is controlled or wnere its management is situated Number 29: Please fli the address ofthe entiy’s Head Office Number 30: Pease fil in the address of any branches, offces, or other place ‘of business ofthe entity situated in indonesia. Number 31: Please fil in the nature of business of the claimant Number 32-38: Please check the appropriate box in accordance with the clalmant's facts and circumstances. Part VI_ for income Earned from Indonesia In Respect to whieh Fale is elalme Number 39: Piease fil in the type of income (e.g. dividend, royalties) interest, or Number 40: Piease fil in the aggregate amount of Income liable to withholding fax under Indonesian Law within @ period of month (Tax Period) Number 41 Piease ll in the type of income from rendering services (including professional. Number 42: Please fil in the aggregate amount of Income liable to withholding fax under Indonesian Law within @ period of month (Tax Period)Number 43: In-case your income is arising from rendering service, please fil in the period when the service is provide. Number 44 Please fil n the other type of income, Number 45: Please fil in the amount of Income liable to withholding tax under Indonesian Law.Lampian Peraturan DeldurJenderal Pak MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA Nomor PER-61/PU2009 DIRECTORATE GENERAL OF TAXES Tanggol 5 November 2009, CERTIFICATE OF DOMICILE OF NON RESIDENT FOR INDONESIA TAX WITHHOLDING (FORM — DGT 2) Guidance: “This frm i to be completed by @ person (ahich includes a body of person, corporate oF on corporate) wha is a resident of a counlry which has concluded Double Taxaon Convention (OTC) with indonesia, who + fs abanking insttuton, of + claims rai fom indonesia Income Tax in respect of income arses ‘rom the transfer of bonds or stocks which traded or Fegjstered n Indonesia stock exchange and eamed the Income or setted the vansaction though @ Custodian in Indonesia, ‘ther than interest and vison [A partculars inthe form ae tobe property furnished and the fom shall be signed as completed. This form must be cetfied by te Competent Author ot his authorizes representative or authorized tax office Inthe county where te come reepient ig a resident boforeeubmited the Cerificate to & Custosian ‘Name of the Country of income Reciplent: o ‘Nama of the Income Recipient a ‘Tax 1D number 0 Adress ” esearch ae ccieciis 1 declare that | am a resident of (51 fram a te ct ofan! for income tax Purposes within the meaning of Double Taxation Convention ofboth countries: 2. Inelation wth the eared income, a am «this company is not acting as an agent ora nominee; (ease choke sex aatngy) 3. The beneficial owner is not an Indonesian resident taxpayer and « | am_ this company is not an Indonesian resident taxpayer and (lave check ba box acorn) 4, Ihave examined the information stated on this form and to the best of my knowledge and belie itis true, corect, and comolete: 6 er) C) % Strut thencane recent or ctl Datetmmiciw) —Capactyinwncvacion Cota Nanbar authotzotosit forhe noe recper CERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF THE COUNTRY eas For the purpoce of tax relief, it ie hereby confirmed that the taxpayer mentioned in Part | ie a resident in (0),rame of estan) within the meaning of the Double Taxation Convention in accordance with Double Taxation Convention concluded between Indonesia and (11) frame of te tte of Date (mmiddiyyyy): Js) ‘are ard Sqn fe Compete ot . ns aumonedrepesenaneorauneraaaaronce | O”A0) Sore aS “office aadress: Capac agatin oF sanaony on This fam is availabe and maybe downloaded at webste iinamaoaisk anid ‘Thi contador 1 vee] months commencina rom te dt of actionINSTRUCTIONS FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR INDONESIA TAX WITHHOLDING (FORM - DGT 2) Number 4 Please fil n the name of the county of income recipient. Number 2: Pease fill in the name ofthe income recipient Number 3: Please fil in the income recipient's taxpayer identification ‘umber in county where the incame recipient is registered as a resident taxpayer. Number 4 Please fil n the income recipient's address. Number 5: This form shall be filed by the management of the claimant Please fil in the name of country where income recipient is, tegistoed ag a resident taxpayer. Number 6: ‘The claimant or his representative (for non individual) shal sign this form Number 7: Please fil the place and date of signin. Number 8: Please fil in the capacity of the claimant or his representative ‘ho signs tis form, Number 9: Please fil the contact number of person who sign ths form. Number 10 and 11: Please fil in the name of county where the claimant is fegistored as a resident taxpayer. Number 12 and 13, ‘The Competent Authorties of his authorized representative or authorizes tax offce should cority this form by signing it The positon ofthe signor should be files in Number 13. Number 14: Please fl in the date when the form is signed by the Competent Authorites or his authorized representative or authorized tax office Number 15: Please fil in the office address of the Competent Authority or authorized representative or authorized tax office.