各省、自治区、直辖市和计划单列市国家税务局：
根据税制改革后的需要，我局对1991年7月1日下发使用的《外国居民享受避免双重征税协定待遇申请表》（国税函发〔1991〕1020号）进行了修改。现将修改后的式样印发你局。请根据你局需要自行印制，于1995年7月1日开始使用。
＿＿税务局 外国居民享受避免双重征税协定待遇申请表
To__Tax Bureau Application for Treatment Under Double Taxation Agreement
一、申请人事项 Details of Claimant: ，１９
┌─────┬─────────┬─────┬────────┬───┐│ 个 人 │姓名 Full name │ │国籍 Nationality│ ││Individual│─────────┼─────┼────────┼───┤│ │住所或居所 │ │邮政编码 │ ││ │Domicile or │ │Postcode │ ││ │resudence │ │ │ │├─────┼─────────┼─────┴────────┴───┤│ │名称 Name │ ││公司或团体├─────────┼─────┬────────┬───┤│Corporati-│总机构所在地 │ │邮政编码 │ ││on or oth-│Place of Head │ │Postcode │ ││er entity │Office │ │ │ ││ ├─────────┼─────┼────────┼───┤│ │实际管理机构所在地│ │邮政编码 │ ││ │Place of effective│ │Postcode │ ││ │management │ │ │ ││ ├─────────┼─────┼────────┼───┤│ │注册所在地 │ │邮政编码 │ ││ │Place of │ │Postcode │ ││ │registration │ │ │ │└─────┴─────────┴─────┴────────┴───┘
二、所得事项 Details of Income
┌─────┬──────────┬─────────────────┐│ 股息 │支付人名称Payer'name│ ││ ├────────┬─┴────┬────────┬───┤│Dividends │地址 Address │ │邮编 Postcode │ ││ ├────────┼──────┼────────┼───┤│ │支付金额 Amount │ │支付日期 │ ││ │of payment │ │Date of Payment │ │├─────┼────────┴─┬────┴────────┴───┤│ 利息 │支付人名称Payer'name│ ││ ├────────┬─┴────┬────────┬───┤│Interest │地址 Address │ │邮编 Postcode │ ││ ├─────┬─┬┴───┬─┬┴───┬─┬──┴─┬─┤│ │支付金额 │ │合同签字│ │合同有效│ │支付日期│ ││ │Amount of │ │日期 │ │期 │ │Date of │ ││ │payment │ │Date of │ │Period │ │payment │ ││ │ │ │contract│ │of │ │ │ ││ │ │ │ │ │contract│ │ │ │├─────┼─────┴─┴──┬─┴─┴────┴─┴────┴─┤│特许权使用│支付人名称Payer'name│ ││费 ├────────┬─┴────┬────────┬───┤│ │地址 Address │ │邮编 Postcode │ ││Royalties ├─────┬─┬┴───┬─┬┴───┬─┬──┴─┬─┤│ │支付金额 │ │合同签字│ │合同有效│ │支付日期│ ││ │Amount of │ │日期 │ │期 │ │Date of │ ││ │payment │ │Date of │ │Period │ │payment │ ││ │ │ │contract│ │of │ │ │ ││ │ │ │ │ │contract│ │ │ │├─────┼─────┴─┴───┬┴─┴────┴─┴────┴─┤│个人劳务所│职业 Occupation │ ││得 ├───────────┼────────────────┤│ │支付人名称 Payer's │ ││Income of │ name │ ││personal ├──────────┬┴─────┬────────┬─┤│service │地址 Address │ │邮编 Postcode │ ││ ├──────────┼─┬────┴┬─┬─────┼─┤│ │支付金额 │ │所得项目 │ │支付日期 │ ││ │Amount of payment │ │Item of │ │Date of │ ││ │ │ │income │ │payment │ │└─────┴──────────┴─┴─────┴─┴─────┴─┘
三、适用的避免双重征税协定 Applicable Double Taxation Agreement:
中华人民共和国同＿＿＿＿＿＿＿＿国签订的避免双重征税协定第＿＿条第＿＿款。
Paragraph____, Article____of the Tax Agreement between the People's
Republic ofChinaand______.
四、声明 Declaration
我仅在此声明以上呈报事项准确无误。
I hereby declare that the above statement is correct and complete tothe best of my knowledge and belief.
申请人签名或盖章：＿＿＿＿＿＿＿
Claimant (Signature or Seal):_______
五、申请人居民身份证明（申请人为其居民的缔约国主管税务机关填写）；或另附对方主管税务机关出具的专用证明。
Certificate of Resident Status of Claimant (For the use of responsible
tax office of theContractingStatein which the claimant is a resident)or attach the special certificate of resident issued by responsible tax
office of theContractingStatein which the claimant is resident.
┌──────────────────────────────────┐│ Certification ││ We certify that_______(claimant's name) is a resident of _______ ││according to the provision of paragraph______, of Article_________ ││is the Double Taxation Agreement between_____and the People's ││Repubic of China. ││ Claimant's serial number: Date: ││ Signature or Stamp of tax office │└──────────────────────────────────┘
以下由中国主管税务机关填写(The following for the use of responsible tax
office of China only): 编号（No.）：第 号
┌──────────────┬────┬────────────┬─┐│收到申请表日期 Date of │ │审核日期 │ ││receipt of application │ │Date of examination │ │├──────────────┼────┴────────────┴─┤│审核意见 │ ││Examination report │ │├──────────────┼───┬─────────────┬─┤│主办人(签字) Responsible │ │负责人(签字) │ ││officer (signature) │ │Chief officer (signature) │ │└──────────────┴───┴─────────────┴─┘
中华人民共和国国家税务总局
State Administration of Taxation The People's Republic of China
主管税务机关盖章
Stamp of tax office
关于填写外国居民享受避免双重征税协定待遇申请表的说明
一、填报范围和程序
（一）本表适用同中华人民共和国签订避免双重征税协定（以下简称税收协定）国家居民取得来源于中国的股息、利息、特许权使用费，以及个人劳务所得申请享受税收协定待遇填报。
（二）本表由受益所有人或所得取得人填写，一式两份，一并送交支付人，由支付人报送当地税务机关。当地税务机关审核认可后，退还支付人一份据以执行。
二、本表填写说明
（一）申请人事项：
１．个人住所或居所填写申请人在税收上为其居民国家的住所或居所地址及邮政编码。
２．公司或团体名称填写公司或团体的全称；总机构、实际管理机构或注册所在地，填写申请人在税收上为其居民国家的总机构所在地、实际管理机构所在地或注册所在地的地址及邮政编码。
（二）所得事项：
个人劳务所得中的职业填写申请人为独立个人劳务或非独立个人劳务；所得项目是指工资、薪金或劳务报酬。
（三）其他事项：
申请人填写对表列各项或其他需要说明的事项。
（四）该表末项所列主管税务机关盖章是指主管申请人提出该项税收业务的中国县（市）级税务机关另盖本级公章。
Instructions of the "Application for Treatment
under Double Taxation Agreement"
1. Scope and procedure of filling the Form
(1) The Form is applicable to those who are residents of the coun-tries concluded the Agreement for the Avoidence of Double Taxation (here-inafter referred to as the "Tax Agreement") with the People's Republic of China, and who claim for treatments of the Tax Agreement with respect todividends, interest, royalties and personal services income derived fromChina.
(2) The Form is completed by beneficial owner or income recipient induplicate forwarded to the payer, then submitted to the relevant local tax office bt the latter, One piece of the duplicate will be returned tothe payer for the enforcement upon tax office's examination and approval.
2. Instructions for items in the Form
(1) "Details of Claimant"
i. Individual's domicile or residence, state the address of claimant'sdomicile or residence as well as postcode in the country of claimant being
a resident for the purpose of tax. ii. Name of corporation or other entity, give full name; Place of headoffice, effective management or registration, give address and postcode in
the country of claimant being a resident for the purpose of tax.
(2) "Details of Income":
"Occupation" in the personal service income column refers to indepen-dent or dependent personal service of the claimant. "item of income" in-cludes wages, salaries or service remuneration.
(3) Others:
Notes necessary by claimant on the items listed in the form or others.
(4) At the close of the Form. "Stamp of tax office" means officialstamp at the level of the tax office of the country (city) ofChinathatis in charge of the said taxation declared by claimant.
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