《非居民纳税人税收居民身份信息报告表（个人适用）》(填写示例）

1、非居民纳税人税收居民身份信息报告表（个人适用）Information Reporting Form of Tax Residence Status of Non-resident Taxpayer For Individuals)填报日期：20XX年X月X日Filling date: Y M D 自行申报 扣缴申报 退税 Self-declaration Withholding declaration Tax refund（据实勾选）一、扣缴义务人基本信息I.Basic Information of Wihholding Agent扣缴义务人名称Name of withholding agentXX市XX公司扣缴义务人纳税人识别号 Tax identification number of withholding agent9XXXXXXXXXXXXX二、非居民纳税人基本信息II. Basic Information of Non-resident Taxpayer非居民纳税人中文姓名Chinese name of non-resident taxpayer XXX非居民纳税人在居民国（

2、地区）姓名Name of no-resident taxpayer in resident state (region)XXX非居民纳税人身份证件类型Type of ID certificate护照/非居民纳税人身份证件号码Number of ID certificateXXXXXXXXX非居民纳税人在中国联系地址和邮政编码Contact address and postal code in ChinaXX市XX区（县、镇）XX路XX号非居民纳税人在居民国（地区）联系地址和邮政编码Contact address and postal code in the rsident state (region)XXXXXXXXX XXXX（据实填写）非居民纳税人在中国的联系电话Telephone number in ChinaXXXX XXXXX非居民纳税人在居民国（地区）的联系电话Telephone number in resident state (region) XXXXX（据实填写）非居民纳税人的居民国（地区）Resident state (region)XX国（地区）非居民纳税人享受税

3、收协定名称Name of the applicable tax treatyXX三、扣缴义务人使用信息III. Informatin for Use by Withholding Agent提示：“税收居民”是指符合缔约国国内税法中对居民定义的人，包括企业和个人。如果非居民纳税人不是需享受税收协定缔约对方的税收居民，则不能享受税收协定待遇。Note: The term tax resident means any person (e.g. an enterprise or individual) who, under the domestic tax law of a contracting party to the ta treaty, shall be regarded as a resident. If the non-resident taxpayer is not a resident of the other contracting party to the tax treaty, he/she shall not be entitled to the treatment

4、under the tax treaty.1、请引述非居民纳税人构成缔约对方税收居民的缔约对方国内法律依据： Please cie the domestic legal basis based on which the non-resident taxpayer qualifies as a tax resident of the other contracting party: XXXXX（据实填写）2、请简要说明非居民纳税人能构成缔约对方税收居民的事实情况： Please briefly describe the facts based on which the non-resident taxpayer qualifies as a tx resident of the other contracting party: XXXXX（据实填写）3、声明： Declaration: 我谨声明，我为需享受税收协定缔约对方的税收居民，我成为缔约对方税收居民并非为了获得税收协定利益而安排。 I hereby declare that I am a tax resident of the o

5、ther contracting party to the tax treaty and the purpose of becoming such a tax resident is not to obtain the tax treaty benefits. 非居民纳税人签章或签字 XXX 20XX年 X月 X 日 Seal or signature of the non-resident taxpayer Y M D四、税务机关管理使用信息IV. Information for Use by Tax Authorities4、根据中华人民共和国个人所得税法规定，在中国境内有住所或者无住所而在境内居住满一年的人是中国的税收居民。根据该法律规定，非居民纳税人是否构成中国的税收居民？ According to the Individual Income Tax Law, an individual will be regarded as a tax resident of China if the individual has a domicile in China or, if the

6、 individual has not a domicile in China, the individual has lived in China for one year. According to such provision, is the taxpayer a tax resident of China? 是 Yes 否 No （据实勾选）5、非居民纳税人在中国境内是否有住所？ Does the non-resident taxpayer have a domicile in China? 是 Yes 否 No （据实勾选）6、非居民纳税人在中国居住时间是以下哪种情况？（据实勾选） Which of the following scenarios does the non-resident taxpayer fall under concerning his or her residence in China? 在一个纳税年度中在中国境内连续或者累计居住不超过183天（含183天） The individual has lived in China for a period

7、or periods not exceeding in the aggregate 183 days within one tax year. 在一个纳税年度中在中国境内居住超过183天但不满1年（临时离境不扣减天数） The individual has lived in China for more than 183 days but less than one year within one tax year (days of temporary departure from China included). 在中国境内居住满1年未满5年 The individual has lived in China for more than one year but less than five years. 在中国境内居住满5年（含5年） The individual has lived in China for five years or more.7、非居民纳税人的永久性住所所在地属于以下哪种情况？（据实勾选） Which of the following scenarios do

8、es the non-resident taxpayer fall under concerning his or her permanent home? 非居民纳税人仅在需享受税收协定缔约对方国家（地区）拥有永久性住所 The non-resident taxpayer has his or her permanent home only in the other contracting state (region). 非居民纳税人仅在中国拥有永久性住所 The non-resident taxpayer has his or her permanent home only in China. 非居民纳税人在需享受税收协定缔约对方国家（地区）和中国均拥有永久性住所 The non-resident taxpayer has his or her permanent homes both in China and the other contracting state (region). 非居民在需享受税收协定缔约对方国家（地区）和中国均没有永久性住所 The non-resident taxpayer has his or her permanent home neither in China nor in the other contracting state (region).8、非居民纳税人如在第三国（地区）拥有永久性住所，请说明具体国家（地区） If the non-resident taxpayer has a permanent home in a third state (region), please provide the name(s) of such state(s) or region(s).XXX（如实填写）9、非居民纳税人的重要利益中心所在地属于以下

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