WHT Type Filing Frequency TIN Payment Date Reference No.

Management Fees
Technical/Professional Fees
Management Fees
Bank Interest

Withholder's TIN

Information on last line

Account Name Phone No. Address

Withholder's Name Withholder's Address Total Number of Withholdees submitted

Country Gross Income Tax Rate Tax Paid Category

Month of Income/ Year of Income Total Amount Total Tax Paid

Quantity - Ozs Quantity - Dwts Quantity - Grns Price per Ozs US Exchange Rate
Payment Method Payment Doc. No.

Cheque 17774AB
Bank Transfer ED7588
Cheque A95663
WHT Electronic Template

Column Headings Example/Explanation Exxon Miners Banks Contractors Last Line

- Rent
- Royalty
- Management Fees
- Technical/Professional Fees
- Loan and Interest
- Deemed Distribution
WHT Type - Gross Distribution for Non-Residents WHT Type WHT Type WHT Type Contractors
- Discount on Treasury Bills
- Other Payments to Non-Residents
- Premium
- Contractors
- Gold Board

- Event Driven
Filing Frequency - Periodic
TIN TIN of the withholdee TIN TIN Primary Account Holder's TIN TIN Withholder's TIN
Contractor's Payment
Payment Date Date of payment that attracts withholding tax Date Transaction Date Interest paid Date Payment Date

Reference No. Unique number that represents transaction SAP Doc # ADVICE# Account No.
Account Name Vendor Name MINER NAME Primary Account Holder's Name Contractor Name Withholder's Name
Phone No. Phone No Phone No Phone No Phone No Withholder's Address
Total Number of Withholdees
Address Address Address Address Address
submitted
Country Country of residence for withholdee Month of Income/ Year of Income
Gross amount on which tax rate is applied; should
Gross Income exclude VAT
WHT base amount -GYD Gross Total Amount
Interest Gross Payment
rate dependent on WHT Type and for Gold Board, the
Tax Rate quantity of gold
Tax Rate Tax Rate Tax Rate Tax Rate

Tax Paid WHT amount - GYD Tax Paid Withholding Tax 2% Deducted Total Tax Paid
Category Category Account Type Description of Contract
Quantity - Ozs Quantity in Ozs
Quantity - Dwts Quantity in Dwts
Quantity - Grns Quantity in Grns
Price per Ozs US Price per Ozs in USD
Exchange Rate Exchange Rate
- Cheque
Payment Method - Cash
Payment Method Payment Method Payment Method Payment Method

Payment Doc. No. Ex. cheque number