ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
2
MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
3
DIRECTORATE GENERAL OF TAXES
4
5
6
FORM DGT
7
8
9
Guidance:
10
1. This form is to be completed by a person (individual or non-individual) that is a resident of a country/jurisdiction that has concluded Double Taxation Agreement (DTA) with Indonesia.
11
12
2. For a person that is a:
13
- banking institution; or
14
- pension fund,
15
complete only page 1.
16
17
3. For an individual, complete PART I and PART II on page 1 and PART IV and PART VII on page 2.
18
19
4. For a non-individual other than those mentioned in no. 2, complete PART I and PART II on page 1 and PART V and PART VI on page 2.
20
21
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 being submitted to Indonesian withholding agent.
22
23
24
25
 Part I INCOME RECIPIENT
26
27
 Tax ID Number:(1)
28
29
 Name:(2)
30
31
 Full address:(3)
32
33
 Country/Jurisdiction:(4)
34
35
 Contact Number:(5)Email :(6)
36
37
Part IICERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF THE COUNTRY OF RESIDENCE
38
39
For the purpose of tax relief, it is hereby confirmed that the taxpayer mentioned in Part I is a tax resident of
40
(7)from(8),(9)to(10)(11)
41
within the meaning of the DTA concluded between Indonesia and
(12)
42
43
44
45
46
(13)(14)_____, __ /__ / __(15)
47
Name & Signature of the Competent Authority orCapacity/designationPlace, date
48
authorized representative or authorized tax office of the signatory(mm/dd/yy)
49
50
Office address:
(16)
51
52
 Part III DECLARATION BY THE INCOME RECIPIENT (BANKING INSTITUTION AND PENSION FUND)
53
54
I declared that:
55
1.
the income recipient is not an Indonesian resident taxpayer;
56
2.
the income recipient is a resident of
(17)
for tax purposes pursuant to the applicable DTA;
57
3.the purposes of the transaction is not to obtain the benefit under the convention directly or indirectly that is contrary to the object and purpose of the DTA;
58
4.
in relation with the earned income, this income recipient is not acting as an agent, nominee, or conduit;
59
5.the beneficial owner is neither an Indonesian resident taxpayer nor a resident taxpayer of the country/jurisdiction other than that mentioned in Part I; and
60
6.I have examined the information stated on this form and it is true, correct and complete to the best of my knowledge and belief.
61
62
63
(18) , / /(19)(20)
64
Signature of the income recipient or individual
Place, date (dd/mm/yyyy)
Capacity/designation
65
authorized to sign for the income recipientof the signatory
66
67
This form is available and can be downloaded on: www.pajak.go.id
68
Page 1
69
70
http://syafrianto.blogspot.com
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100