KEMENTERIAN KEUANGAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PAJAK
PERATURAN DIREKTUR JENDERAL PAJAK
NOMOR PER- 40 /PJ/2010
TENTANG
PENGEMBALIAN KELEBIHAN PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK TERUTANG
BAGI WAJIB PAJAK LUAR NEGERI
DIREKTUR JENDERAL PAJAK,
:
Menimbang
a.
bahwa berdasarkan ketentuan Pasal 32A Undang-Undang Nomor 7 Tahun 1983
tentang Pajak Penghasilan sebagaimana telah beberapa kali diubah terakhir dengan
Undang-Undang Nomor 36 Tahun 2008 diatur bahwa pemerintah berwenang untuk
melakukan perjanjian dengan pemerintah negara lain dalam rangka penghindaran
pajak berganda dan pencegahan pengelakan pajak ;
b . bahwa dalam rangka melaksanakan ketentuan Pasal 9 Peraturan Menteri Keuangan
Nomor 190/PMK .03/2007 tentang Tata Cara Pengembalian Kelebihan Pembayaran
Pajak Yang Seharusnya Tidak Terutang,
bahwa berdasarkan pertimbangan sebagaimana dimaksud dalam huruf a dan huruf
b, perlu menetapkan Peraturan Direktur Jenderal Pajak tentang Pengembalian
Kelebihan Pembayaran Pajak Yang Seharusnya Tidak Bagi Wajib Pajak Luar
Negeri ;
Mengingat
:
1 .
Undang-Undang Nomor 6 Tahun 1983 tentang Ketentuan Umum dan Tata Cara
Perpajakan (Lembaran Negara Republik Indonesia Tahun 1983 Nomor 49,
Tambahan Lembaran Negara Republik Indonesia Nomor 3262) sebagaimana telah
beberapa kali diubah terakhir dengan Undang-Undang Nomor 16 Tahun 2009
(Lembaran Negara Republik Indonesia Tahun 2009 Nomor 62, Tambahan
Lembaran Negara Repulbik Indonesia Nomor 4999) ;
2.
Undang-Undang Nomor 7 Tahun 1983 tentang Pajak Penghasilan (Lembaran
Negara Republik Indonesia Tahun 1983 Nomor 50, Tambahan Lembaran Negara
Republik Indonesia Nomor 3263) sebagaimana telah beberapa kali diubah terakhir
dengan Undang-Undang Nomor 36 Tahun 2008 (Lembaran Negara Republik
Indonesia Tahun 2008 Nomor 133, Tambahan Lembaran Negara Republik
Indonesia Nomor 4893) ;
3.
Peraturan Menteri Keuangan Nomor 188/PMK .03/2007 tentang
Pengembalian Kelebihan Pembayaran Pajak ;
4.
Peraturan Menteri Keuangan Nomor 190/PMK .03/2007 tentang Tata Cara
Pengembalian Kelebihan Pembayaran Pajak Yang Seharusnya Tidak Terutang ;
Tata Cara
MEMUTUSKAN :
Menetapkan
PAJAK
TENTANG PENGEMBALIAN
DIREKTUR
JENDERAL
: PERATURAN
KELEBIHAN PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK TERUTANG BAGI
WAJIB PAJAK LUAR NEGERI
4
Pasal 1
Dalam Peraturan Direktur Jenderal Pajak ini yang dimaksud dengan :
1.
Persetujuan Penghindaran Pajak Berganda yang selanjutnya disebut P3B adalah
perjanjian antara Pemerintah Indonesia dengan pemerintah negara/jurisdiksi lain
dalam rangka penghindaran pajak berganda dan pencegahan pengelakan pajak .
2 . Wajib Pajak luar negeri selanjutnya disebut WPLN adalah subjek pajak luar negeri
sebagaimana dimaksud dalam Undang-Undang Nomor 7 Tahun 1983 tentang Pajak
Penghasilan sebagaimana telah beberapa kali diubah terakhir dengan UndangUndang Nomor 36 Tahun 2008 .
3.
Pemotong/Pemungut Pajak adalah badan pemerintah, subjek pajak dalam negeri,
penyelenggara kegiatan, bentuk usaha tetap, atau perwakilan perusahaan luar
negeri lainnya yang diwajibkan untuk melakukan pemotongan atau pemungutan
pajak atas penghasilan yang diterima atau diperoleh WPLN sesuai ketentuan yang
berlaku, termasuk P3B .
4 . Pajak Yang Seharusnya Tidak Terutang adalah pajak atas penghasilan yang
diterima atau diperoleh WPLN yang seharusnya tidak dipotong atau dipungut oleh
Pemotong/Pemungut Pajak sesuai dengan ketentuan yang berlaku, termasuk P3B .
5.
Pejabat Yang Berwenang adalah pejabat yang berwenang sebagaimana dimaksud
dalam P3B .
6.
Prosedur Persetujuan Bersama atau Mutual Agreement Procedures selanjutnya
disebut MAP adalah prosedur yang dijalankan oleh Pejabat Yang Berwenang akibat
penerapan P3B yang tidak sebagaimana mestinya sesuai dengan ketentuan yang
diatur dalam P3B .
7.
Kesepakatan Dalam Rangka MAP (mutual agreement) adalah kesepakatan antara
Pejabat Yang Berwenang dari Indonesia dan Pejabat Yang Berwenang dari negara
mitra P3B dalam rangka menjalankan MAP sesuai dengan ketentuan yang diatur
dalam P3B .
8.
Surat Keterangan Domisili yang selanjutnya disebut SKD adalah formulir Certificate
of Domicile of Non Resident for Claiming Tax Refund of Indonesia Tax Withholding
(Form-DGT 5) yang diisi oleh WPLN .
9.
Kantor Pelayanan Pajak yang selanjutnya disebut KPP adalah Kantor Pelayanan
Pajak tempat Pemotong/Pemungut Pajak terdaftar sebagai Wajib Pajak
Pemotong/Pemungut Pajak .
10 . Surat Pemberitahuan Masa yang selanjutnya disebut SPT Masa adalah Surat
Pemberitahuan yang digunakan oleh Pemotong/Pemungut Pajak untuk melaporkan
penghitungan dan penyetoran atas pemotongan atau pemungutan pajak yang telah
dilakukan untuk suatu Masa Pajak tertentu sesuai dengan ketentuan yang berlaku .
Pasal 2
Pajak Yang Seharusnya Tidak Terutang atas penghasilan yang diterima atau diperoleh
WPLN meliputi :
a.
kesalahan pemotongan atau pemungutan pajak yang mengakibatkan pajak yang
dipotong atau dipungut oleh Pemotong/Pemungut Pajak lebih besar daripada pajak
yang seharusnya dipotong atau dipungut berdasarkan ketentuan yang berlaku,
termasuk P3B ;
b.
pemotongan atau pemungutan pajak atas penghasilan yang bukan objek pajak ; atau
c.
pemotongan atau pemungutan pajak yang lebih besar daripada yang seharusnya
berdasarkan ketentuan yang diatur dalam P3B sesuai dengan Kesepakatan Dalam
Rangka MAP .
Pasal 3
(1) Wajib Pajak yang dapat mengajukan permohonan pengembalian kelebihan
pembayaran Pajak Yang Seharusnya Tidak Terutang sebagaimana dimaksud
dalam Pasal 2 adalah WPLN yang tidak menjalankan kegiatan atau usaha melalui
bentuk usaha tetap di Indonesia .
(2) Permohonan sebagaimana dimaksud pada ayat (1) harus diajukan oleh WPLN
melalui Pemotong/Pemungut Pajak .
Pasal 4
(1) Permohonan sebagaimana dimaksud dalam Pasal 3 ayat (1) harus memenuhi
persyaratan sebagai berikut :
a . diajukan secara tertulis kepada Direktur Jenderal Pajak melalui Kepala KPP
dengan menggunakan Form-DGT 3 sebagaimana ditetapkan dalam Lampiran I
Peraturan Direktur Jenderal Pajak ini ;
b.
Form-DGT 3 sebagaimana dimaksud pada huruf a harus :
1) diisi dengan benar, Iengkap, dan jelas ;
2) diisi dalam bahasa Inggris ;
3) ditandatangani oleh WPLN ;
4) mencantumkan alasan permohonan WPLN secara jelas ; dan
5)
mencantumkan jumlah pajak yang diminta untuk dikembalikan ;
c . dilampiri dengan surat kuasa, dan
d . dilengkapi dengan dokumen pendukung .
(2) Permohonan yang tidak memenuhi persyaratan sebagaimana dimaksud pada ayat
(1) dianggap bukan surat permohonan pengembalian kelebihan pembayaran Pajak
Yang Tidak Seharusnya Terutang, sehingga tidak dipertimbangkan .
Pasal 5
Pemotong/Pemungut Pajak harus menyampaikan permohonan WPLN yang telah
memenuhi persyaratan sebagaimana dimaksud dalam Pasal 4 kepada Kepala KPP .
Pasal 6
Surat kuasa sebagaimana dimaksud pada Pasal 4 ayat (1) huruf c harus dibuat oleh
WPLN dengan memenuhi syarat-syarat sebagai berikut :
a.
menggunakan Form-DGT 4 sebagaimana ditetapkan dalam Lampiran II Peraturan
Direktur Jenderal Pajak ;
b.
Form-DGT 4 sebagaimana dimaksud pada huruf a harus :
1) diisi dengan benar, Iengkap, dan jelas ;
2) diisi dalam bahasa Inggris ;
3) ditandatangani oleh WPLN ; dan
4) dilunasi Bea Meterai yang terutang sesuai dengan ketentuan peraturan
perundang-undangan perpajakan yang berlaku .
5) mencantumkan pernyataan pemberian kuasa kepada Pemotong/Pemungut
Pajak untuk menyampaikan permohonan pengembalian kelebihan pembayaran
Pajak Yang Seharusnya Tidak Terutang beserta kelengkapannya ke KPP dan
untuk menerima pengembalian kelebihan
bertindak mewakili WPLN
pembayaran Pajak Yang Seharusnya Tidak Terutang .
Pasal 7
(1) Dokumen pendukung sebagaimana dimaksud dalam Pasal 4 ayat (1) huruf d terdiri
dari :
a . SKD dengan menggunakan Form-DGT 5 sebagaimana ditetapkan dalam
Lampiran III Peraturan Direktur Jenderal Pajak ini ;
b . bukti pemotongan/pemungutan pajak asli yang dimintakan pengembalian
kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang ;
c.
surat pernyataan WPLN bahwa pajak yang dimintakan pengembalian belum
diperhitungkan dengan pajak WPLN yang terutang di luar negeri dan/atau belum
dibebankan sebagai biaya dalam penghitungan penghasilan kena pajak WPLN
di luar negeri ;
d . dalam hal WPLN adalah subjek pajak dalam negeri dari negara/jurisdiksi mitra
P3B Indonesia dan menerima atau memperoleh penghasilan yang pasal terkait
dalam P36 memuat klausul beneficial owner, yaitu :
1) nama, alamat, kewarganegaraan, dan informasi rinci mengenai dewan
direksi ;
2) identitas dan informasi rinci mengenai pemegang saham ;
3) jumlah pegawai dan informasi rinci mengenai tugasnya ;
4) penjelasan atas investasi yang menimbulkan penghasilan ;
5) sumber pendanaan investasi ;
6) penggunaan atau rencana penggunaan penghasilan yang bersumber dari
Indonesia ; dan
7) laporan keuangan dan surat pemberitahuan pajak untuk tahun yang
mencakup saat terjadinya transaksi dan 2 (dua) tahun sebelumnya ;
e . dokumen yang berkaitan dengan jenis penghasilan :
1) bunga :
a) perjanjian pemberian atau penyediaan pinjaman/utang ;
b) jurnal pencatatan penerimaan bunga,
c)
rekening bank penerimaan dan penggunaan penghasilan, dan
d)
notice of interest computation ;
2) dividen :
a) dividend declaration dari perusahaan yang membayar dividen ;
b) rekening bank penerimaan dan penggunaan penghasilan, dan
c) surat keterangan dari pembayar dividen yang menyatakan bahwa
pemohon adalah pemegang saham yang berhak menerima dividen ;
3) royalti, sewa, dan penghasilan lain dari penggunaan harta :
a) perjanjian yang terkait dengan penyediaan harta ;
b) jurnal pencatatan penerimaan penghasilan,
c) rekening bank penerimaan dan penggunaan penghasilan, dan
d)
notice of income computation ;
4) imbalan jasa, baik yang dilakukan oleh individu maupun badan :
a) perjanjian pemberian/penyediaan jasa ;
b) pernyataan WPLN bahwa WPLN tidak menjalankan kegiatan atau usaha
di Indonesia melalui suatu bentuk usaha tetap ; dan
c) surat keterangan dari Pemotong/Pemungut Pajak mengenai lamanya
pelaksanaan pemberian/penyediaan jasa di Indonesia ;
5) penghasilan dari penjualan atau pengalihan saham perusahaan di Indonesia :
a) perjanjian penjualan atau pengalihan saham ; dan
b) akta pemindahan hak atas saham yang dijual atau dialihkan dari
perusahaan di Indonesia yang sahamnya dijual atau dialihkan ;
6) premi asuransi dan premi reasuransi :
a) polis asuransi/reasuransi ; dan
b) notice of premium computation ;
7) branch profit bentuk usaha tetap :
a) Surat Pemberitahuan Tahunan Pajak Penghasilan bentuk usaha tetap ;
dan
b) surat keterangan Wajib Pajak bentuk usaha tetap yang menerangkan
alasan pemotongan pajak atas branch profit ;
8) penghasilan Iainnya :
a) pernyataan Pemotong/Pemungut Pajak bahwa WPLN adalah pemilik sah
atas penghasilan ; dan
b) penjelasan WPLN mengenai substansi penghasilan ; dan
f.
dokumen lain yang menurut WPLN atau Pemotong/Pemungut Pajak perlu
disampaikan kepada Direktur Jenderal Pajak .
(2) Form-DGT 5 sebagaimana dimaksud pada ayat (1) huruf a hanya dipersyaratkan
bagi WPLN yang merupakan subjek pajak dalam negeri di negara/jurisdiksi mitra
P3B dan harus memenuhi persyaratan sebagai berikut :
a . diisi oleh WPLN dengan benar, Iengkap, dan jelas ;
b . ditandatangani oleh WPLN atau diberi tanda yang setara dengan tanda tangan
sesuai dengan kelaziman di negara/jurisdiksi mitra P3B ;
c . telah disahkan oleh Pejabat Yang Berwenang, wakilnya yang sah, atau pejabat
kantor pajak yang berwenang di negara/jurisdiksi mitra P3B, yang dapat berupa
tanda tangan atau diberi tanda yang setara dengan tanda tangan sesuai dengan
kelaziman di negara/jurisdiksi mitra P3B ; dan
d . dalam hal WPLN tidak dapat memperoleh pengesahan Pejabat Yang Berwenang
di negara/jurisdiksi mitra P3B pada Form-DGT-5 sebagaimana dimaksud pada
huruf c, pengesahan dimaksud dapat digantikan dengan surat keterangan
domisili asli yang lazim disahkan atau diterbitkan oleh negara/jurisdiksi mitra P3B
dengan memenuhi persyaratan sebagai berikut :
1) menggunakan bahasa Inggris ;
2) sekurang-kurang nya mencantumkan informasi mengenai nama WPLN ;
3) menyebutkan tahun pajak yang mencakup penghasilan yang terkait dengan
Pajak Yang Seharus Tidak Terutang ; dan
4
4) mencantumkan tanda tangan Pejabat Yang Berwenang, wakilnya yang sah,
atau pejabat kantor pajak yang berwenang di negara mitra P3B atau tanda
yang setara dengan tanda tangan sesuai dengan kelaziman di
negara/jurisdiksi mitra P3B dan nama pejabat dimaksud .
(3) Dalam hal permohonan WPLN terkait dengan pelaksanaan Kesepakatan Dalam
Rangka MAP sebagaimana dimaksud dalam Pasal 2 huruf c, dokumen pendukung
sebagaimana dimaksud dalam Pasal 4 ayat (1) huruf d terdiri dari :
a . bukti pemotongan/pemungutan pajak asli yang dimintakan pengembalian
kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang ; dan
b . fotokopi surat Kesepakatan Dalam Rangka MAP .
Pasal 8
Dalam rangka menyelesaikan permohonan WPLN, Direktur Jenderal Pajak melalui
Kepala KPP :
a.
melakukan penelitian atas permohonan pengembalian kelebihan pembayaran Pajak
Yang Seharusnya Tidak Terutang ;
b . dapat meminta keterangan dari Pemotong/Pemungut Pajak, WPLN, Pejabat Yang
Berwenang di negara mitra P3B, dan/atau pihak lain .
Pasal 9
(1) Permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak
Terutang ditolak dalam hal berdasarkan hasil penelitian sebagaimana dimaksud
dalam Pasal 8 huruf a :
a . WPLN merupakan subjek pajak dalam negeri Indonesia ;
b.
pajak yang dipotong atau dipungut belum disetor oleh Pemotong/Pemungut
Pajak ;
c.
pajak yang dipotong atau dipungut telah :
1) diperhitungkan dengan pajak WPLN yang terutang di luar negeri,
2) telah dibebankan sebagai biaya dalam penghitungan penghasilan kena
pajak WPLN di luar negeri, atau
3) ditanggung oleh atau menjadi beban Pemotong/Pemungut Pajak ;
d . permohonan WPLN tidak sesuai dengan ruang lingkup P3B ;
e . terjadi penyalahgunaan P3B sebagaimana dimaksud dalam ketentuan mengenai
pencegahan penyalahgunaan P3B ; atau
f.
pajak yang dipotong atau dipungut oleh Pemotong/Pemungut Pajak telah sesuai
dengan ketentuan yang berlaku, termasuk P3B .
(2) Permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak
Terutang terkait dengan pelaksanaan Kesepakatan Dalam Rangka MAP
sebagaimana dimaksud dalam Pasal 2 huruf c ditolak dalam hal berdasarkan
penelitian sebagaimana dimaksud dalam Pasal 8 huruf a :
a.
pajak yang dipotong atau dipungut belum disetor oleh Pemotong/Pemungut
Pajak ; atau
b . jumlah kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang menurut
permohonan WPLN Iebih besar daripada jumlah kelebihan pembayaran Pajak
Yang Seharusnya Tidak Terutang berdasarkan Kesepakatan Dalam Rangka
MAP .
k
(3) Permohonan WPLN yang bukan berasal dari negara/jurisdiksi mitra P3B Indonesia
ditolak dalam hal berdasarkan hasil penelitian sebagaimana dimaksud dalam Pasal
8 huruf a :
a . WPLN merupakan subjek pajak dalam negeri Indonesia ;
b . pajak yang dipotong atau dipungut belum disetor oleh Pemotong/Pemungut
Pajak ;
c.
pajak yang dipotong atau dipungut telah :
1) diperhitungkan dengan pajak WPLN yang terutang di luar negeri,
2) dibebankan sebagai biaya dalam penghitungan penghasilan kena pajak
WPLN di luar negeri, atau
3) ditanggung oleh atau menjadi beban Pemotong/Pemungut Pajak ; atau
d . pajak yang dipotong atau dipungut telah sesuai dengan ketentuan yang berlaku .
(4) Dalam hal terdapat pajak yang dipotong atau dipungut, namun belum disetor oleh
Pemotong/Pemungut Pajak, Kepala KPP menagih pajak yang terutang kepada
Pemotong/Pemungut Pajak sesuai ketentuan yang berlaku .
(5) Dalam hal SPT Masa belum dilaporkan oleh Pemotong/Pemungut Pajak, Kepala
KPP harus menindaklanjutinya sesuai ketentuan yang berlaku .
Pasal 10
(1) Setelah melakukan penelitian sebagaimana dimaksud dalam Pasal 8 huruf a, Kepala
KPP atas nama Direktur Jenderal Pajak menerbitkan Surat Ketetapan Pajak Lebih
Bayar atas nama Pemotong/Pemungut Pajak q .q . WPLN, apabila terdapat Pajak
Yang Seharusnya Tidak Terutang, paling lama 3 (tiga) bulan sejak permohonan
WPLN diterima secara lengkap .
(2) Dalam hal permohonan WPLN ditolak, Direktur Jenderal Pajak melalui Kepala KPP
harus memberitahukan secara tertulis kepada WPLN melalui Pemotong/Pemungut
Pajak paling lama 3 (tiga) bulan sejak permohonan WPLN diterima secara lengkap
dan dengan menyebutkan alasan penolakannya .
(3) Berdasarkan Surat Ketetapan Pajak Lebih Bayar sebagaimana dimaksud pada ayat
(1), Kepala KPP atas nama Direktur Jenderal Pajak menerbitkan Surat Keputusan
Pengembalian Kelebihan Pembayaran Pajak atas nama Pemotong/Pemungut Pajak
q .q . WPLN sesuai dengan ketentuan yang berlaku .
(4) Atas dasar Surat Keputusan Pengembalian Kelebihan Pembayaran Pajak
sebagaimana dimaksud pada ayat (3), Kepala KPP atas nama Menteri Keuangan
menerbitkan Surat Perintah Membayar Kelebihan Pembayaran Pajak atas nama
Pemotong/Pemungut Pajak q .q . WPLN sesuai dengan ketentuan yang berlaku
dengan mencantumkan nomor rekening bank yang berada di Indonesia milik
Pemotong/Pemungut Pajak dan dengan menggunakan mata uang Rupiah .
Pasal 11
Pada saat berlakunya Peraturan Direktur Jenderal Pajak ini, Surat Edaran Direktur
Jenderal Pajak Nomor SE-09/PJ .10/1994 tentang Restitusi Pajak Penghasilan Pasal 26
Sehubungan Dengan Ketentuan Dalam PPPB dinyatakan tidak berlaku, kecuali untuk
permohonan pengembalian Pajak Penghasilan Pasal 26 dalam rangka penerapan
ketentuan P3B yang telah diajukan oleh WPLN sebelum berlakunya Peraturan Direktur
Jenderal Pajak ini .
4
Pasal 11
Peraturan Direktur Jenderal Pajak ini mulai berlaku pada tanggal ditetapkan .
Ditetapkan di Jakarta
padatanggal 9 Agust us 2010
N
D TJIPTARDJO
4281975121002
Lampiran I
Peraturan Direk(urJenderal
L~o
Pajak
Nomor PER/PJ/2010
TENTANG PENGEMBALIAN KELEBIHAN
PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK
TERUTANG BAGI WAJIB PAJAK LUAR NEGERI
MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
DIRECTORATE GENERAL OF TAXES
APPLICATION FORM
FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 3)
I the undersigned :
Name
(1)
Address
(2)
Phone No. (_)
acting as : ) O the claimant himself-individual
O
the claimant himself-management of non individual entity
(3)
Information of the claimant :
Name
(4)
Taxpayer ID No .
(5)
Address
(6)
Phone No .(_)
(7)
Country/jurisdiction
to claim refund for the following tax withheld in Indonesia :
Withholding Tax Slip (No. and Dat
(A)
(additional paper may be used)
(8)
Tax Withheld (Rupiah
(B)
Tax Refund Claimed (Rupiah
(C)
1.
2.
3.
4.
Total
The above tax as mentioned in column B withheld by Indonesia withholding tax agent :
Name
( 9)
Taxpayer ID number
( 10 )
(11)
Address
Reasons of refund claim :
(additional paper may be used)
(12)
Documents attached : (13) •)
•
•
•
Power of Attorney (completed Form-DGT 4)
•
Documents to support the statement of beneficial ownership, which consists of 7 items .
Certificate of Domicile (completed Form-DGT 5)
(required only if claimant is resident of Indonesian DTC partner)
Original withholding tax slip(s) :piece(s)
(required only if claimant is resident of
Indonesian DTC partner and related article(s) in DTC mentions the beneficial owner phrase)
•
•
Documents related to the earned income
Statement of Claimant that the tax claimed has not been utilized to reduce the liable tax in the claimant's
country/jurisdiction nor to deduct the taxable income in the claimant's country/jurisdiction .
•
Other document(s), please specify
(if any) :
Declaration :
I declare that the information stated in this form is true, correct and complete .
Place and Date (mm/dd/yyyy) (14)
) Please
Signature of the claimant or individual
authorized to sign for the claimant (15)
Capacity in which acting (16)
check the appropriate box
FORM-DGT 3
4
INSTRUCTIONS
FOR APPLICATION FORM FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING
(FORM-DGT 3)
General Information :
1.
Non resident who has been withheld income tax by
Indonesia withholding tax agent may claim tax refund to
the Director General of Taxes, in case :
a.
b.
the non resident considers that the tax withheld is not
in accordance with Indonesian income tax law and/or
Double
Taxation
Convention/Agreement
(DTC)
concluded by Indonesia and his domicile country/
jurisdiction, or
the non resident claims tax refund as the agreed
result of Mutual Agreement Procedures conducted by
the Competent Authorities of Indonesia and of treaty
partner .
2.
The application must be made by non resident taxpayer
who claims the refund ("the Claimant") and must be
submitted through the Indonesia withholding tax agent .
3.
One application must be made for any tax claims related
to one withholding tax agent .
4 . The Claimant must grant a specific power of attorney to
the withholding tax agent to lodge the application to the
Director General of Taxes and to provide a bank account
which will be used to transfer the approved tax refund .
5.
Documents and information that are required to be
provided by the Claimant (please read the related
instructions for details) :
a.
The application (completed Form-DGT 3),
b.
The power of attorney (completed Form-DGT 4),
c.
The certificate of domicile (completed Form-DGT 5)which is only required only if the Claimant is resident
of the Indonesia DTC partner),
d.
The withholding tax slips (original),
e.
The Claimant statement that the tax claimed has not
been utilized to reduce the liable tax nor to deduct the
taxable income in calculating the liable tax in the
claimant's country/jurisdiction,
f.
Specific documents related to the earned income,
9.
Specific documents/information to support the
beneficial ownership statement, which is only required
if the Claimant is resident of Indonesia DTC partner
and the related article(s) in DTC mentions the
beneficial owner phrase .
6.
Director General of Taxes shall give a decision not more
than 3 (three) months since the application is lodged
completely. Should the application is refused ; a written
notification will be sent to the Claimant through the
withholding tax agent.
7.
An Overpayment Tax Assessment Letter (SKPLB) will be
issued for approved claim to process the refund transfer to
the withholding tax agent's bank account . For transferring
any tax refund, it is required a bank account, Rupiah
currency, in any bank that is situated in Indonesia .
Number 4 to 6 :
This section must be filled with information of the Claimant
whose income is withheld by Indonesia withholding tax agent .
(4) Please fill in the Claimant's name .
(5) Please fill in the Claimant's taxpayer identification number
in country/jurisdiction where the claimant registered as a
taxpayer resident.
(6) Please fill in the Claimant's address .
(7) Please fill in the country/jurisdiction where the claimant
registered as a taxpayer resident .
Number 8 :
Please fill in the column (A) with the number and date of
withholding tax slip(s) issued by withholding tax agent, column
(B) with the amount of tax withheld as stated in the withholding
tax slip (in Rupiah) and column (C) with the amount of tax
claimed (in Rupiah) .
Please total the amount of column (B) and (C) respectively .
Additional paper may be used .
Number 9-11 :
This section requires the claimant to fill in the information
regarding Indonesia withholding tax agent . You may refer to
information provided in withholding tax slips .
(9) Please fill in the name of the withholding tax agent .
(10) Please fill in the taxpayer identification number (NPWP) of
the withholding tax agent .
(11) Please fill in the address of the withholding tax agent.
Number 12 :
Please provide reasons to claim the tax withheld and any
articles of the Double Tax Convention (DTC) which relevant or
related to the claim . The Claimant may state his reasons and
arguments to support that the tax withheld is not in accordance
with the Indonesian income tax law and/or the DTC . Additional
paper may be used by the claimant .
Number 13 :
Please check the appropriate box to declare that the Claimant
has completed all the requirements .
Notes : The failure to present the following attachment will
cause the Director General of Taxes to refuse the application .
a.
Power of Attorney (completed Form-DGT 4) . The form
is downloadable at h ttp ://www.paiak .cio .i d . The Claimant
must provide a specific power of attorney to grant power to
the withholding tax agent to submit the application and to
provide a bank account number . This document is liable to
Indonesian stamp duty (IDR 6,000) according to the Law
No . 13 Year 1985 .
b.
Certificate of Domicile (completed Form-DGT 5) . The
form is downloadable at http ://www .paiak .go .i d . This form
is required to be submitted for the application of the DTC .
The form of certificate of domicile, issued by the
Directorate General of Taxes and must be filled
completely and signed by the Claimant . The first page of
this certificate must be authorized by the Competent
Authorities, his representative or authorized tax office in
country/jurisdiction where the Claimant is registered as a
taxpayer resident . In case the competent authority, his
authorized representative, or the authorized tax office
cannot put his authorization in this form, the Claimant may
submit the certificate of domicile, as an attachment of
Form-DGT 5, which is usually issued in the Claimant's
country/jurisdiction and such certificate shall meet the
requirements as provided in the instruction of Form-DGT 5 .
c.
Original withholding tax slip(s) . The Claimant must
provide the original withholding tax slips to support the
information provided in Number 8 .
Guidance to fill the application :
Form-DGT 3 is downloadable at http ://www.paiak .oo .id :
Number 1 :
Please fill in the name of individual who signs this form . For
individual, please fill in the name of the Claimant . For non
individual entity, please fill in the name of individual who may
act as the representative of the Claimant .
Number 2 :
Please fill in the address of individual who signs this form .
Number 3 :
Please check the appropriate box .
A
INSTRUCTIONS
FOR APPLICATION FORM FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING
(FORM-DGT 3)
d.
The Claimant statement that the tax claimed has not been
utilized to reduce the liable tax nor to deduct the taxable
income in calculating the liable tax in the Claimant's
country/jurisdiction .
These documents are required to be submitted by the
claimant who is a resident in country/jurisdiction that has
concluded DTC with Indonesia and the related article in
DTC mentions the beneficial owner phrase .
e.
Document(s) related to the earned income .
To support that the Claimant is the beneficial owner of the
income, the following information (7 items) must be
provided as attachment of the application (completed
Form-DGT 3) :
1)
Name, address, nationality and other detailed
information of board of directors ;
1)
2)
3)
4)
Interest income :
a)
the loan agreement,
b)
the recording journal of the receipt of income,
c)
the bank statement that showing the receipt and
the use of income, and
d)
a notice of interest computation ;
3)
Number of employees and detailed job description ;
a declaration of dividend distribution issued by
the Indonesian entity who paid the dividend,
4)
Description of investment which generates the
income related to the tax claimed ;
b)
the bank statement that showing the receipt and
the use of income, and
5)
Financial sources of the investment ;
6)
c)
a statement letter made by the company who
distributed the dividend mentioning that the
claimant is the rightful owner of dividend ;
The use or the plan of use of income generated by
the investment ;
The Claimant's financial statements and reported
income tax return for year when the payment
occured and for the 2 (two) years before .
Royalties, rent and other income related to the
use of or for the right to use asset, property or
equipment :
a)
the related agreement,
b)
the recording journal of the receipt of income,
c)
the bank statement that showing the receipt and
the use of income, and
d)
a notice of income computation ;
a)
the related service agreement;
b)
a statement letter made by the claimant
mentioning that claimant conducted business or
activities in Indonesia not through a permanent
establishment,
a statement letter issued by the Indonesian
withholding tax agent mentioning that the
claimant rendered services in Indonesia for a
period not more than the period stipulated in the
DTC to constitute a permanent establishment ;
Gains from the alienation of shares :
the agreement related to the alienation of shares
of a company situated in Indonesia,
Notary deed on transfer of right of the alienated
shares .
Insurance or reinsurance premium :
a)
f.
9.
Other documents
The Claimant or the withholding tax agent may attach
documents other than the required documents mentioned
above to support the claim .
Notes :
a.
b.
In case the tax claimed by the Claimant is resulted from
mutual agreement agreed by both Competent Authorities
through a Mutual Agreement Procedures, the claimant is
only required to submit the following documents :
1)
Power of Attorney (completed Form-DGT 4),
2)
Original withholding tax slip(s), and
3)
Copy of mutual agreement . This document is
in
produced by both Competent Authorities
conducting the Mutual Agreement Procedures
In case the Claimant is not a resident taxpayer of a
country/jurisdiction which has concluded DTC with
Indonesia, the Claimant is only required to submit the
following documents :
1)
Power of Attorney (completed Form-DGT 4),
2)
Original withholding tax slip(s),
3)
The Claimant statement that the tax claimed has not
been utilized to reduce the liable tax nor to deduct the
taxable income in calculating the liable tax in the
Claimant's country/jurisdiction, and
4)
Document(s) related to the earned
mentioned in No .13 .d .
the insurance policy, and
b) a notice of premium computation ;
branch profit of a permanent establishment :
a)
the insurance policy,
b)
the annual income tax return of the related
in
permanent establishment that situated
Indonesia,
a statement letter issued by the permanent
establishment who acts as the withholding tax
agent concerning the ground of the tax
withholding .
c)
8)
7)
Income from services, rendered by individual or
non individual :
b)
7)
detailed
Dividend income :
a)
6)
Name, address, shares and other
information concerning the shareholders ;
a)
c)
5)
2)
Other income :
a)
a statement letter issued by the Indonesian
withholding tax agent mentioning that the
Claimant is the rightful owner of the income ;
b)
a description by the claimant regarding the
substance of income, including the underlying
transaction .
Documents to support the statement of beneficial
ownership
income as
Number 14 :
Please fill in the venue and date of signing .
Number 15 :
The Claimant or the representative must sign the form .
Number 16 :
Please fill in the capacity of the Claimant or the representative
who signs this form .
Lampiran II
Peraturan Direktur Jenderal Pajak
Nomor PER- L~O /PJ/2010
TENTANG PENGEMBALIAN KELEBIHAN
PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK
TERUTANG BAGI WAJIB PAJAK LUAR NEGERI
MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
DIRECTORATE GENERAL OF TAXES
I
POWER OF ATTORNEY
FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 4)
The undersigned :
Name
Address
Phone No .(
acting as *) :
)
(3)
O the claimant (for Individual)
17 the claimant (representative of non individual entity)
Information of the claimant :
Name
(4)
Taxpayer ID No .
Address
(5)
(6)
Phone No .(_)
(7)
Country/Jurisdiction :
herewith gives the power of attorney to (Indonesia withholding tax agent) :
Name
(8)
Taxpayer ID No .
(9)
Address
(10)
Phone No .(j
to lodge the application for claiming tax refund of Indonesia tax withholding (completed Form-DGT 3),
including the required attachments, to the Director General of Taxes, and to act on my behalf to receive
the tax refund approved by the Director General of Taxes .
This power of attorney is made to be used for the purposes so indicated .
,
/
/(11)
Place and date (mm/dd/yyyy)
(12)
Signature of the proxy
*) Please
check the appropriate box .
FORM•DGT 4
(14)
(13)
Signature of the claimant or individual
authorized to sign on behalf of the claimant
Capacity in which acting
INSTRUCTIONS
FOR FORM OF POWER OF ATTORNEY (FORM-DGT 4)
General information :
This form is one of the required documents which granting a
power of attorney to Indonesia withholding tax agent to lodge
the refund application (completed Form-DGT 3) and all
required attachments and to act on behalf the Claimant to
receive any tax refund approved by the Director General of
Taxes .
It is required to provide an account in any bank situated in
Indonesia in Indonesia Rupiah (IDR) currency.
Guidance to fill this form :
Number 1 :
Please fill in the name of individual who signs this form . For
individual, please fill in the name of the Claimant . For non
individual entity, please fill in the name of individual who may
act as the representative of the entity .
Number 2 :
Please fill in the address of individual who will sign the power
of attorney.
Number 3 :
Please check the appropriate box .
Number 4 :
Please fill in the Claimant's name . If the Claimant is an
individual, the name is as it is filled in Number 1 .
Number 5 :
Please fill in the Claimant's taxpayer identification number in
country/jurisdiction where the claimant registered as a taxpayer
resident .
Number 6 :
Please fill in the claimant's address .
Number 7 :
Please fill in the country/jurisdiction where the claimant
registered as a taxpayer resident .
Number 8-10 :
Please fill in the information of Indonesia withholding tax agent
who receives the power of attorney . The information may be
appeared in the withholding tax slip .
(8) Please fill in the name of the withholding tax agent,
(9) Please fill in the taxpayer identification number (NPWP),
(10) Please fill in the address .
Number 11 :
Please fill in the venue and date of signing .
Number 12 :
The person who receives the power of attorney must sign this
form .
Number 13 :
The Claimant, or the representative of non individual claimant,
must sign this form .
Number 14 :
Please fill in capacity of the Claimant who signs this form . In
case the signor is the representative, please fill in the capacity
of the signor .
Note :
The Power of Attorney is liable to Indonesian stamp duty (IDR
6,000) according to Law No . 13 Year 1985 .
i
J
Lamp- III
Peraturan Direktur enderaI Pajak
Nomor PER/PJ/2010
TENTANG PENGEMBALIAN KELEBIHAN
PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK
TERUTANG BAGI WAJIB PAJAK LUAR NEGERI
MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
DIRECTORATE GENERAL OF TAXES
CERTIFICATE OF DOMICILE OF NON RESIDENT
FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 5)
Guidance :
• Do not use this form to claim benefit of Double Taxation Convention/Agreement (DTC) at the time you earn income from the
Indonesia withholding tax agent .
• This form is only required to be completed by a person (which includes a body of person, corporate or non corporate) who is a
resident of a country/jurisdiction that has concluded a DTC with Indonesia .
• This form consists of 2 (two) pages and all particulars are to be properly furnished and this form shall be completed and signed by the
claimant, not by the Indonesia withholding tax agent .
• Part III must be certified by the competent authorities, his authorized representative or the authorized tax office in the country or
jurisdiction where the claimant is a taxpayer resident .
I
AME OF COUNTRY/JURISDICTION OF THE CLAIMANT
I
(1)
INFORMATION OF THE CLAIMANT
Tax ID Number
(2)
Full Name
(3)
Address
(4)
DECLARATION AND STATEMENT OF BENEFICIAL OWNERSHIP BY THE CLAIMANT
Part II :
(5) (full name)
1
O
hereby declare that :
I am (authorized to sign for) the beneficial owner of income stated in the completed Form-DGT 3 (this statement must be
filled only if the related article in the DTC mentions the beneficial owner phrase) ;
(73 I am
O This entity is *)
not an Indonesian taxpayer resident; and
I have examined the information provided in this form and to the best of my knowledge and belief it is true, correct, and
complete .
(6)
Signature of the income recipient or individual
authorized to sign for the income recipient
(7)
-/-/
Date (mm/dd/yy)
(8)
Capacity in which acting
BY
COMPETENT
AUTHORITY
CERTIFICATION
COUNTRY/JURISDICTION OF RESIDENCE
AUTHORIZED
(9)
Contact Number
TAX
OFFICE
THE
For the purpose of tax relief, it is hereby confirmed that the taxpayer mentioned in Part I is a resident in
(10) [name of the country/jurisdiction of residence] within the meaning of the Double Taxation
Convention/Agreement in accordance with Double Taxation Convention/Agreement concluded between Indonesia and
(11) [name of the country/jurisdiction of residence] .
(12)
Name and signature of the Competent Authority, his
authorized representative or authorized tax office
Date (mm/dd/yyyy) :
//(14)
Office address :
This form isavailable and may be downloadedatthis website: http:/w ww.pajak .go .id
*) Please check the appropriate box
Page 1
FORM-DGT 5
k
W
Lampiran III
Peraturan Direktur Jenderal Pajak
Nomor PER- 44
/PJ/2010
TENTANG PENGEMBALIAN KELEBIHAN
PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK
TERUTANG BAGI WAJIB PAJAK LUAR NEGERI
MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
DIRECTORATE GENERAL OF TAXES
CERTIFICATE OF DOMICILE OF NON RESIDENT
FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 5)
Part IV
TO BE COMPLETED IF THE CLAIMANT IS AN INDIVIDUAL
(16)
1 . Name :
2 . Date of birth (mm/dd/yyyy)
3 . Are you acting as an agent or a nominee?
(17)
n
Yes
D
No *)
(18)
4 . Full address :
(19)
5 . Do you have a permanent home in Indonesia?
o
Yes
(20)
No ~
o
(21)
6 . Country where you reside ordinarily :
7 . Have you ever been resided in Indonesia?
o
Yes
o
No*)
If so, in what period?
/
/
/
to
/
(22)
And, please provide the address
.~
8 . Do you have any office, or other place of business in Indonesia?
El
(23)
Yes o No
If so, please provide the address
9 . Is the transaction structured by reason only to take advantage of benefit of the DTC?
Part V
o
Yes
(24)
o No *)
TO BE COMPLETED IF THE CLAIMANT IS A NON INDIVIDUAL
Country of registration/incorporation :
(25)
Country where the place of management or control reside :
(26)
Address of Head Office :
(27)
Address of branches, offices, or other place of business in Indonesia (if any) :
(28)
Nature of business (Pension Fund, Insurance, Bank, Financing, etc .)
(29)
(30)
Is the entity acting as an agent or a nominee?
n Yes o No *)
The creation of the entity and/or the transaction structure is not solely motivated by reason
to take the advantage of benefit of the DTC
o Yes o No *)
(31)
o Yes o No *)
The entity is listed in stock market and the shares are regularly traded . If yes, please
provide the name of the stock market :
(32)
The entity has its own management to conduct the business and such management has an
o Yes
D
No*)
o Yes
o No*)
(33)
independent discretion .
10 . The entity employs sufficient qualified personnel .
(34)
This form is available and may be downloaded at this website : http:://www .oajak.(7 o.id
*)
Please check the appropriate box
I declare that I have examined the information provided in this form and to the best of my knowledge and belief it is true,
correct and complete .
(35)
Signature of the income recipient or individual
authorized to sign for the income recipient
// (36)
Date (mm/dd/yy)
Page 2
FORM-DGT 5
(37)
Capacity in which acting
Contact Number
( 38 )
INSTRUCTIONS
FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA
TAX WITHHOLDING (FORM-DGT 5)
In case the Claimant is not the beneficial owner, do not
check the box;
General information :
1.
This form is only required for the Claimant whose
country/jurisdiction
has concluded
Double Taxation
Convention/Agreement (DTC) with Indonesia .
b.
2.
This form consists of 2 (two) pages . The first page consists
of the Claimant declaration and authorization by the
Competent Authority or authorized tax office in the
Claimant's country/jurisdiction concerning the status of the
Claimant's residency .
Number 6 :
The Claimant or his representative (for non individual) must sign
this form .
After the Claimant fills this form completely please bring the
first page to the competent authority or authorized tax office
for authorization .
In case the competent authority or the authorized tax office
cannot put his authorization in this form, the Claimant may
submit the certificate of domicile, as an attachment of FormDGT 5, which is usually issued in the Claimant's
country/jurisdiction and such certificate shall meet the
requirements as provided in the instruction of Form-DGT 5:
a.
It must be written in English ;
b.
It states at least the name of the Claimant ;
c.
It mentions the fiscal year which covers the period
when the income, related to the tax claimed, is derived ;
and
d.
It bears the signature and the name of the competent
authority, his authorized representative or the
authorized tax officer .
The second page consists of information related to the
Claimant which is required to be signed by the Claimant .
Authorization by the competent authority or authorized tax
office is not necessary for information in this second page .
Guidance to fill this form :
Number 1 :
Please fill in the name of country/jurisdiction of the Claimant .
Part I Information of Claimant :
Number 2 :
Please fill in the Claimant's taxpayer identification number in
country where the Claimant is registered as a resident taxpayer .
Please type "n .a ." in case the country/jurisdiction of the Claimant
does not provide taxpayer identification number for resident
taxpayers .
Number 3 :
Please fill in the Claimant's name .
whether the Claimant is the Indonesian taxpayer resident .
Do not check the box if the Claimant is Indonesian resident
taxpayer .
Number 7 :
Please fill in the date of signing .
Number 8 :
Please fill in the capacity of the Claimant or his representative
who signs this form .
Number 9 :
Please fill in the contact number of person who signs this form .
Part III Certification by competent authority of the country
of residence :
In case the Competent Authority, His authorized representative
or the authorized tax office cannot put his authorization in this
form, the Claimant may leave blank this Part . Then, the Claimant
must attach the certificate of domicile, which is commonly issued
in the Claimant's country/jurisdiction, to the completed FormDGT 5 .
Number 10 and 11 :
Please fill in the name of country/jurisdiction where the Claimant
is resident taxpayer .
Number 12 and 13
The Competent Authorities, his authorized representative, or
authorized tax office certifies this form by signing it . The position
of the signor should be filled in Number 13 .
Number 14 :
Please fill in the date when the form is signed by the competent
authority, his authorized representative or authorized tax office
Number 15 :
Please fill in the office address of the competent authority,
authorized representative or authorized tax office .
Part IV To be completed if the Claimant is an Individual :
Number 16 :
Please fill in the Claimant's full name .
Number 17 :
Please fill in the Claimant's birthday .
Number 18 :
Number 4 :
Please fill in the Claimant's address .
Part II Declaration by the Claimant :
Number 5 :
Please fill in the name of person who authorized to sign on
behalf the Claimant .
If the Claimant is not an individual, this form must be filled by
individual who may act as representative of the non individual
entity .
If the Claimant is an individual, please fill in the name as stated
in Number 3 .
Important :
The Claimant is required to state :
a.
whether the Claimant is the beneficial owner of income . The
phrase beneficial owner is commonly contained in article of
DTC related to the income of dividend, interest, royalties
and capital gain (sometimes) . It is highly recommended to
the Claimant to check article in DTC related to the income .
Please check the appropriate box . You are considered acting as
an agent if you act as an intermediary or acting for and on behalf
of other party in relation with the income source in Indonesia .
You are considered acting as a nominee if you are the legal
owner of income or of assets that the income is generated but
not the real owner of the income or assets .
Number 19:
Please fill in the Claimant's address .
Number 20:
Please check the appropriate box . If the Claimant's permanent
home is in Indonesia, you are considered as Indonesian
taxpayer resident in accordance with the Indonesian Income Tax
Law . In that case the DTC cannot be applied to the Claimant .
Number 21 :
Please fill the name of country where the Claimant ordinarily
resides .
r
0
INSTRUCTIONS
FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA
TAX WITHHOLDING (FORM-DGT 5)
Number 22 :
Please check the appropriate box. In case the Claimant has ever
been resided in Indonesia, please fill the period of your stay and
address where you resided .
Number 23 :
Please check the appropriate box . In case the Claimant has any
offices, or other place of business in Indonesia, please fill in the
address of office or other place of business in Indonesia .
Number 24 :
Please state whether or not the Claimant's motivation in
structuring the transaction related to the earned income is solely
to take advantage of benefit of the DTC .
Part V To be Completed if the Claimant is non Individual :
Number 25 :
Please fill in the country/jurisdiction where the entity is registered
or incorporated .
Number 26 :
Please fill in the country where the entity is controlled or where
its management is situated .
Number 27 :
Please fill in the address of the entity's head office .
Number 28 :
Please fill in the address of any branches, offices or other place
of business of the entity situated in Indonesia .
Number 29 :
Please fill in the nature of business of the Claimant .
Number 30-38 :
Please check the appropriate box in accordance with the
Claimant's facts and circumstances .
(30) Please check "No" if the entity, in relation with the earned
income, is acting as an agent or a nominee . The meaning of
agent or nominee is mentioned in Number 18 .
(31) Please state whether or not motivation of the Claimant
related to the earned income is solely to take advantage of
benefit of the DTC .
(32) Please state whether or not the entity is listed in stock
market and, if so, please type the name of the stock market .
(33) Please state whether the entity has its own management to
conduct the business and such management has an
independent discretion .
(34) Please state whether the entity employs sufficient qualified
personnel .
Number 35 :
The Claimant or his representative (for non individual) must sign
this form .
Number 36:
Please fill in the date of signing .
Number 37 :
Please fill in the capacity of the Claimant or his representative
who signs this form .
Number 38 :
Please fill in the contact number of person who signs this form .
R
F
INSTRUCTIONS
FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA
TAX WITHHOLDING (FORM-DGT 5)
General information :
1.
2.
This form is only required for the Claimant whose
country/jurisdiction has concluded Double Taxation
Convention/Agreement (DTC) with Indonesia .
This form consists of 2 (two) pages . The first page consists
of the Claimant declaration and authorization by the
Competent Authority or authorized tax office in the
Claimant's country/jurisdiction concerning the status of the
Claimant's residency .
If the Claimant is an individual, please fill in the name as stated
in Number 3 .
Important :
The Claimant is required to state :
a.
whether the Claimant is the beneficial owner of income . The
phrase beneficial owner is commonly contained in article of
DTC related to the income of dividend, interest, royalties
and capital gain (sometimes) . It is highly recommended to
the Claimant to check article in DTC related to the income .
In case the Claimant is not the beneficial owner, do not
check the box;
b.
whether the Claimant is the Indonesian taxpayer resident .
Do not check the box if the Claimant is Indonesian resident
taxpayer .
After the Claimant fills this form completely please bring the
first page to the competent authority or authorized tax office
for authorization .
In case the competent authority or the authorized tax office
cannot put his authorization in this form, the Claimant may
submit the certificate of domicile, as an attachment of FormDGT 5, which is usually issued in the Claimant's
country/jurisdiction and such certificate shall meet the
requirements as provided in the instruction of Form-DGT 5 :
Number 6 :
The Claimant or his representative (for non individual) must sign
this form .
a.
It must be written in English ;
b.
It states at least the name of the Claimant ;
Number 7 :
Please fill in the date of signing .
c.
It mentions the fiscal year which covers the period
when the income, related to the tax claimed, is derived ;
and
Number 8 :
Please fill in the capacity of the Claimant or his representative
who signs this form .
d.
It bears the signature and the name of the competent
authority, his authorized representative or the
authorized tax officer .
Number 9 :
Please fill in the contact number of person who signs this form .
The second page consists of information related to the
Claimant which is required to be signed by the Claimant .
Authorization by the competent authority or authorized tax
office is not necessary for information in this second page .
Guidance to fill this form :
Number 1 :
Please fill in the name of country/jurisdiction of the Claimant .
Part I Information of Claimant :
Number 2 :
Please fill in the Claimant's taxpayer identification number in
country where the Claimant is registered as a resident taxpayer .
Please type "n .a ." in case the country/jurisdiction of the Claimant
does not provide taxpayer identification number for resident
taxpayers .
Number 3 :
Please fill in the Claimant's name .
Number 4 :
Please fill in the Claimant's address .
Part Ill Certification bV competent authority of the country
of residence :
In case the Competent Authority, His authorized representative
or the authorized tax office cannot put his authorization in this
form, the Claimant may leave blank this Part . Then, the Claimant
must attach the certificate of domicile, which is commonly issued
in the Claimant's country/jurisdiction, to the completed FormDGT 5 .
Number 10 and 11 :
Please fill in the name of country/jurisdiction where the Claimant
is resident taxpayer .
Number 12 and 13
The Competent Authorities, his authorized representative, or
authorized tax office certifies this form by signing it . The position
of the signor should be filled in Number 13 .
Number 14 :
Please fill in the date when the form is signed by the competent
authority, his authorized representative or authorized tax office
Number 15 :
Please fill in the office address of the competent authority,
authorized representative or authorized tax office .
Part II Declaration by the Claimant :
Part IV To be completed if the Claimant is an Individual :
Number 5 :
Please fill in the name of person who authorized to sign on
behalf the Claimant.
Number 16 :
Please fill in the Claimant's full name .
If the Claimant is not an individual, this form must be filled by
individual who may act as representative of the non individual
entity .
Number 17 :
Please fill in the Claimant's birthday .