A03056非居民纳税人享受税收协定待遇情况报告表个人.doc

Axxxx6《非居民纳税人享受税收协定待遇情况报告表（个人 所得税A表）》【分类索引】业务域优惠业务类别税收优惠表单类型纳税人填报设置依据（表单来源）政策规定表单【政策依据】《国家税务总局关于发布〈非居民纳税人享受税收协定待遇管理办法〉 的公告》（国家税务总局公告2xx5年第60号）【表单】非居民纳税人享受税收协定待遇情况报告表（个人所得税 A表）Reporting Form for Non-resident Taxpayer Claiming Tax Treaty Benefits（Form A for Individual Income Tax）（享受税收协定股息、利息、特许权使用费条款待遇适用）(Applicable to Tax Treaty Benefits under Articles of Dividends, Interest or Royalties)填表日期： 年月日货币单位：元人民币Filli ng date:YCurre ncy un it: RMBM D0自行申报0 扣缴申报0退税Self-declarati on Withholdi ng declarati onTax refu nd一、扣缴义务人基本信息I. Basic Information of Withholding Agent扣缴义务人 名称Name of withholdi ng age nt扣缴义务人纳 税人识别号Taxide ntificati on n umber of withholdi ng age nt二、非居民纳税人基本信息II. Basic Information of Non-resident Taxpayer非居民纳税 人中文名称Chin esen ame onon-reside nttaxpayer非居民纳税人 在居民国(地 区)姓名Name of non-reside nt taxpayer in reside nt state (regio n)非居民纳税 人身份证件 类型Type of IDcertificae非居民纳税人 身份证件号码Number of IDcertificate非居民纳税 人享受税收 协定名称Name of the applicable tax treaty所得类型Type of in comeO 股息Divide nds O 利息In terest O 特许权使用费 Royalties三、扣缴义务人使用信息III. Information for Use by Withholdi ng Agent(一)享受股息条款待遇填写(I) Claiming Tax Treaty Benefits under the Article of Dividends1 •非居民纳税人直接拥有支付股息的公司的股份比例Direct shareholing perce ntage of the non-reside nt taxpayer in the divide nd pay ing compa ny*2 •非居民纳税人直接或间接拥有支付股息公司的股份比 例合计Perce ntage of total share capital held, directly andin directly, by the non-reside nt taxpayer in the divide nd pay ing compa ny非居民纳税人在该公司的投资金额Amou nt of in vestme nt in the divide nd pay ing compa ny by the non-reside nt taxpayer金额：Amou nt:币种：Curre ncy:(二)享受利息条款待遇填写(II) Claiming Tax Treaty Benefits under the Article of Interest*3 •贷款资金是否存在以下情况Do any of the following circumstances apply in respect of the loaned monies?(1 )□由税收协定缔约对方符合条件的政府或机构间接提供资金The loa ned monies are in directly provided by gover nment or in stituti on of the other tax treaty con tract ing party in circumsta nces in which such in directly finan ced loa ns qualify for ben efits un der the terms of the treaty(2) □ 由税收协定缔约对方符合条件的政府或机构提供担保A guarantee is provided by a government or institution of the other tax treaty con tract ing party in circumsta nces in which such guara nteed loa ns qualify for ben efits un der theterms of the treaty(3) □由税收协定缔约对方符合条件的政府或机构提供保险In sura nee is provided by a gover nment or in stituti on of the other tax treaty con tract ing party in circumsta nces in which such in sured loa ns qualify for benefts un der the terms of the treaty*4 •如贷款资金由税收协定缔约对方符合条件的政府或机 构间接提供资金、担保或保险，请填写符合条件的政府或 机构全称Please provide the full n ame of the qualified gover nment or in stituti on if loa ns/fu nds, a guara ntee or in sura nce are in directly provided by a qualified gover nme t or in stituti on of the other tax treaty con tract ing party(三)享受特许权使用费条款待遇填写(III) Claiming Tax Treaty Benefits under the Article of Royalties5 •据以产生该项特许权使用费的权利或财产属于以下哪种类型？To which of the follow ing types of right or property do the royalties fall in to?(1) 口文学、艺术或科学著作Literature, artistic or scie ntific work(2) 口 专利、商标、设计、模型、图纸、秘密配方或秘密程序Pate nt, trademark, desig n, model, pla n, secret formula or process(3) 口 工业、商业、科学设备Equipme nt for in dustrial, commercial or scie ntific use(4) 口 有关工业、商业、科学经验的信息In formati on con cer ning in dustrial, commercial and scie ntific experie nce(5) 口其他特许权使用费Other royalties6 •该所得是否属于飞机、船舶租赁所支付的特许权使用 费？Is the in come attributable toroyalty paid for aircraft leas ing or ship charteri ng?□是 Yes□否No7 .请简要描述据以产生特许权使用费所得的具体权利或财产。

Please give a briefdescripti on of the specific right or property from which the royalty in come derives.(四)其他信息(IV) Other Information8 •该项所得是否与非居民纳税人设在中国的常设机构或固 定基地有实际联系？Is the in come effectively conn ected with a perma nent establishme nt or fixed base of the non-reside nt taxpayer in Chi na?□是 Yes□否No9 •非居民纳税人是否通过代理人取得该项所得？Did the non-reside nt taxpayer receive the in come via a age nt?□是 Yes□否NoXX •非居民纳税人为该项所得的 受益所有人”的声明Declarati on by non-reside nt taxpayer as the "be neficial own er" of the in come提示：受益所有人”是指对所得或所得据以产生的权利或财产具有所有权和支配权的 人。

如果非居民纳税人不是来源于中国的股息、利息或特许权使用费所得的受益所有人，贝9 不能享受税收协定待遇Note: A "be neficial own er" refers to a pers on that owns and has the right to dispose of the in come or the rights or property from which such in come derives. A non-reside nt taxpayer who is not the ben eficial owner of the divide nds, in terest or royalties sourced in China is not en titled to the tax treaty ben efits.(1)非居民纳税人是否对所得或所得据以产生的财产或权 利具有控制权或处置权？Does the non-reside nt taxpayer have con trol over or the right to dispose of the in come or the property or rights from which such in come derives?□是 Yes□否No(2)非居民纳税人是否对所得或所得据以产生的财产或权 利承担相应风险？Des the non-reside nt taxpayer bear the risks associated with the in come or the proper。