Series C No.

30 (2014)
PEOPLE’S DEMOCRATIC REPUBLIC OF ALGERIA
MINISTRY OF FINANCE
DIRECTORATE-GENERAL OF TAXES Intended for the Authority of
the State of Residence

CENTRAL DIRECTORATE……………..……………………………….
ADDRESS :…………………………………………………………………..
TELEPHONE :……………..…………FAX :……………………….EMAIL :………………..………………………….

CERTIFICATE OF RESIDENCE OVERSEAS

Request to apply the tax convention between People’s Democratic Republic of

Algeria and

Indicate in this heading the name of the contracting State

1- Description of Incomes’ Receiver:

Name and surname or corporate name:………………………………………………………………….
Date and place of birth (for natural persons) : …………………………………….-
Profession or business nature: ………………………………………….…………………………
Residential or head office address : ………………………………………………………….

2- Statement of Revenues’ Receiver:

The undersigned, described above, certifies having achieved the following conditions::
- he is the actual beneficiary of revenues for which the convention is requested;
- he has the quality of resident of ……………..……………………….within the meaning of the above mentioned tax convention ;
- he has no permanent facility in Algeria or a fixed base to which the below mentioned incomes relate.
Issued at…………..……….on,……………………. signature of the benificiary or his representative.

3- Nature of Incomes :

Dividends Interests Royalties

4- Statement of tax authority of State of residence:

The undersigned, representative of the tax authority of……………………………..………….……….., certifies that, to the best of his/her knowledge, the
indications given by the declaring party on the application hereof correspond to its actual situation and that the actual beneficiary of the above indicated
incomes:
- has the quality of resident of............................................................... within the meaning of the above mentioned tax convention;
- is within his jurisdiction, and that he is identified under tax number................................................................................
Issued at…………..……….on,……………………. Name, surname and quality of the signatory

5- Statement of the Algerian Debtor :…………….

Name of Corporation Name :
Address: Cyber Parc,
Tax Identification Number :
Number of taxable item :

We certify that we have paid to the above indicated beneficiary, for the year......................., incomes included herein on a net basis, namely after deduction of
the tax levied by deduction at source at the rate set by the above mentioned tax convention. The net amount of incomes paid to the beneficiary
represents....................0,00 for Dividends,...............................................................0,00 for interests and...........................................0,00 for royalties.
Issued at Alger. on,……………………. Name, surname and quality of the signatory