STM1 (Pind.

2014)

BORANG PERMOHONAN SIJIL TARAF MASTAUTIN

APPLICATION FORM FOR CERTIFICATE OF RESIDENCE
Nama Pembayar Cukai /
Name of Taxpayer

Nombor Rujukan Cukai Pendapatan /

Income Tax Reference Number

Perniagaan Utama (Dalam Bahasa Inggeris)/

Principal business activity (In English)

Alamat Perniagaan / Business Address

Negara Pejanji / Treaty Country

Tahun Taksiran diperlukan /

Year of Assessment required

Jenis Pendapatan diterima /

Type of Income received

Tempoh Bayaran / Period of Payment

Jumlah Pendapatan diterima / RM

Amount of payment received

Nama dan alamat pembayar Asing / Name and

address of Foreign Payer

Pengakuan oleh Pemohon/ Declaration by Applicant

Saya mengesahkan bahawa permohonan ini dibuat untuk menuntut manfaat di bawah Perjanjian
Pengelakan Pencukaian Dua Kali, dan semua maklumat yang diberikan adalah benar dan betul /
I confirm that the application is made for the purpose of claiming the benefit under the Avoidance of Double
Taxation Agreement, and all information given in this application is true and correct

Tandatangan / Signature

…………………………………… Tarikh / Date …………………………..

Nama Pemohon / Name of Applicant: …………………………………………………………………………………….

Nombor Pengenalan (KP/ Pasport/ Tentera/ Polis)/

Identification Number (IC/ Passport/ Military / Polis): ……………………………………………………………………….

Jawatan Pemohon / Designation of Applicant: ……………………………………………………………………………

Alamat Surat-menyurat Pembayar Cukai/ Correspondence Address of Taxpayer: ……………………………

………………………………………………………………………………………………………………………………………

Alamat e-mel Pemohon/ Applicant’s email address: …………………………………………………………………….

Nama dan Nombor Telefon orang boleh dihubungi/

Name and telephone number of contact person

………………………………………………………………………………………………………………………………………

1
 STM1 (Pind. 2014)
PERINGATAN/ NOTES:

PASTIKAN SEMUA BORANG NYATA CUKAI PENDAPATAN TELAH DIKEMBALIKAN

DALAM TEMPOH/ ALL RETURN FORMS SHOULD HAVE BEEN SUBMITTED DURING
THE STIPULATED PERIOD

Cara memohon / How to apply

1. Borang STM1 hendaklah dilengkapkan dengan sempurna untuk semua permohonan STM/
Form STM1 duly completed for all COR application

2. Gunakan Borang STM1A bagi memohon lebih daripada 1 sijil / Use Form STM1A if
application is for more than 1 certificate.

3. Dokumen yang perlu disertakan/ Documents need to be attached

i. Syarikat / Company

a. Jika borang nyata masih belum patut dikemukakan, sertakan salinan Minit
Mesyuarat Lembaga Pengarah atau surat pengesahan pengarah berkenaan
pengurusan dan kawalan syarikat dilakukan di Malaysia/ If the return form is not
due yet, a copy of the Minutes of Board of Directors’ Meeting, or a letter signed by
a director confirming the management and control of the company are exercised in
Malaysia;

b. Borang 49 dari Suruhanjaya Syarikat Malaysia (SSM) / Form 49 from Companies

Commission of Malaysia (CCM)

ii. Individu / Individual

a. Pasport asal dan salinan / Original passport and photocopy

b. Senarai pergerakan keluar / masuk Malaysia / List of movement in / out of Malaysia

iii. Perkongsian / Partnership

a. Pasport asal ahli kongsi individu serta salinannya / Original passport (and
photocopy) of the partner applying;

b Senarai pergerakan ahli kongsi individu keluar/masuk Malaysia / List of movement

of the individual partner in/out of Malaysia.

iv. Badan Amanah / Trust

Salinan suratikatan penubuhan Badan Amanah (bagi fail baru daftar) / A copy of the
trust deed (for newly registered file)