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MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
(FORM DGT)
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DIRECTORATE GENERAL OF TAXES
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CERTIFICATE OF DOMICILE OF NON RESIDENT
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FOR INDONESIA WITHHOLDING TAX
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Guidance :
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1. This form is to be completed by a person (which includes a body of a person, corporate or non corporate) who is a
resident of a country which has concluded Double Taxation Convention (DTC) with Indonesia
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2. For person who is:
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- a banking institution, or
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- a pension fund,
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Completes only DGT Page 1
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3. For individual, completes PART I and PART II of DGT Page 1, and PART IV and PART VII of DGT Page 2.
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4. For non individual other than mentioned in Number 2, completes PART I and PART II of DGT Page 1, and PART V, PART
VI, and PART VII of DGT Page 2
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All particulars in the form are to be properly furnished, and the form shall be signed as completed. This form must be certified by the Competent Authority or his authorized representative or authorized tax office in the country where the income recipient is a tax resident before submitted to Indonesian withholding agent/custodian.
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 PART I INCOME RECIPIENT
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 Tax ID Number:(1)
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 Name:(2)
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 Full address:(3)
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 Country:(4)
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 Contact Number:(5)email :(6)
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PART IICERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF THE
COUNTRY OF RESIDENCE
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For the purpose of tax relief, it is hereby confirmed that the taxpayer mentioned in Part I is a resident in
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(7)for the period (8)(9)to(10)(11)within
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the meaning of the Double Taxation Convention in accordance with Double Taxation Convention concluded between
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Indonesia and
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(13)(14)___ / ___ / _____(15)
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Name and Signature of the Competent Authority orCapacity/designation of
Place, date (mm/dd/yy)
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his authorized representative or authorized tax office signatory
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Office address :
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 PART III DECLARATION BY THE INCOME RECIPIENT (BANKING INSTITUTION AND PENSION FUND)
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I declared that:
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1.
This company is not an Indonesian resident taxpayer;
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2.
This company a resident of
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for income tax purposes within the meaning
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of DTC of both countries;
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3.
the purposes of the transaction is not to obtain the benefit under the convention directly or indirectly that is contrary to the
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object and purpose of the DTC;
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4.
in relation with the earned income, this company is not acting as an agent, nominee or conduit;
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5.
the beneficial owner is not an Indonesia resident taxpayer and/or not a resident taxpayer of the country other than
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mentioned in Part I; and
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6.
I have examined the information stated on this form and to the best knowledge and belief it is true, correct and complete.
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(18) , / /(19)(20)
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Signature of the income recipient or individualPlace, date (mm/dd/yy)Capacity in which acting
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authorized to sign for the income recipient
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This form is available and may be downloaded at this website: http:/www.pajak.go.id
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DGT Page 1
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