1、A03056非居民纳税人享受税收协定待遇情况报告表（个人所得税A表） 非居民纳税人享受税收协定待遇情况报告表（个人所得税 A表）Reporting Form for Non-resident Taxpayer Claiming Tax Treaty Benefits(Form A for Individual Income Tax)（享受税收协定股息、利息、特许权使用费条款待遇适用）(Applicable to Tax Treaty Benefits under Articles of Dividends, Interest or Royalties)填表日期： 年 月 日Filling da
2、te: Y M D 货币单位：元人民币Currency unit: RMB 自行申报 扣缴申报 退税Self-declaration Withholding declaration Tax refund一、扣缴义务人基本信息I. Basic Information of Withholding Agent扣缴义务人名称Name of withholding agent扣缴义务人纳税人识别号Tax identification number of withholding agent二、非居民纳税人基本信息II. Basic Information of Non-resident Taxpayer
3、非居民纳税人中文名称Chinese name of non-resident taxpayer非居民纳税人在居民国（地区）姓名Name of non-resident taxpayer in resident state (region)非居民纳税人身份证件类型Type of ID certificat非居民纳税人身份证件号码Number of ID certificatee非居民纳税人享受税收协定名称Name of the applicable tax treaty所得类型Type of income 股息 Dividends 利息 Interest 特许权使用费 Royalties三、扣缴
4、义务人使用信息III. Information for Use by Withholding Agent(一)享受股息条款待遇填写(I) Claiming Tax Treaty Benefits under the Article of Dividends1非居民纳税人直接拥有支付股息的公司的股份比例 Direct shareholding percentage of the non-resident taxpayer in the dividend paying company*2非居民纳税人直接或间接拥有支付股息公司的股份比例合计Percentage of total share capi
5、tal held, directly and indirectly, by the non-resident taxpayer in the dividend paying company非居民纳税人在该公司的投资金额Amount of investment in the dividend paying company by the non-resident taxpayer金额：Amount:币种：Currency:（二）享受利息条款待遇填写 (II) Claiming Tax Treaty Benefits under the Article of Interest*3贷款资金是否存在以下
6、情况Do any of the following circumstances apply in respect of the loaned monies?（1） 由税收协定缔约对方符合条件的政府或机构间接提供资金The loaned monies are indirectly provided by government or institution of the other tax treaty contracting party in circumstances in which such indirectly financed loans qualify for benefits un
7、der the terms of the treaty（2） 由税收协定缔约对方符合条件的政府或机构提供担保A guarantee is provided by a government or institution of the other tax treaty contracting party in circumstances in which such guaranteed loans qualify for benefits under the terms of the treaty（3） 由税收协定缔约对方符合条件的政府或机构提供保险Insurance is provided by
8、 a government or institution of the other tax treaty contracting party in circumstances in which such insured loans qualify for benefits under the terms of the treaty*4如贷款资金由税收协定缔约对方符合条件的政府或机构间接提供资金、担保或保险，请填写符合条件的政府或机构全称 Please provide the full name of the qualified government or institution if loan
9、s/funds, a guarantee or insurance are indirectly provided by a qualified government or institution of the other tax treaty contracting party(三) 享受特许权使用费条款待遇填写(III) Claiming Tax Treaty Benefits under the Article of Royalties5据以产生该项特许权使用费的权利或财产属于以下哪种类型？To which of the following types of right or prope
10、rty do the royalties fall into?（1） 文学、艺术或科学著作 Literature, artistic or scientific work（2） 专利、商标、设计、模型、图纸、秘密配方或秘密程序 Patent, trademark, design, model, plan, secret formula or process（3） 工业、商业、科学设备Equipment for industrial, commercial or scientific use（4） 有关工业、商业、科学经验的信息Information concerning industrial,
11、 commercial and scientific experience（5） 其他特许权使用费 Other royalties 6该所得是否属于飞机、船舶租赁所支付的特许权使用费？Is the income attributable to a royalty paid for aircraft leasing or ship chartering? 是 Yes 否 No 7请简要描述据以产生特许权使用费所得的具体权利或财产。 Please give a brief description of the specific right or property from which the ro
12、yalty income derives.(四) 其他信息 (IV) Other Information8该项所得是否与非居民纳税人设在中国的常设机构或固定基地有实际联系？Is the income effectively connected with a permanent establishment or fixed base of the non-resident taxpayer in China? 是 Yes 否 No 9非居民纳税人是否通过代理人取得该项所得？Did the non-resident taxpayer receive the income via an agent?
13、 是 Yes 否 No 10非居民纳税人为该项所得的“受益所有人”的声明Declaration by non-resident taxpayer as the “beneficial owner“ of the income提示：“受益所有人”是指对所得或所得据以产生的权利或财产具有所有权和支配权的人。如果非居民纳税人不是来源于中国的股息、利息或特许权使用费所得的受益所有人，则不能享受税收协定待遇。Note: A “beneficial owner“ refers to a person that owns and has the right to dispose of the income
14、or the rights or property from which such income derives. A non-resident taxpayer who is not the beneficial owner of the dividends, interest or royalties sourced in China is not entitled to the tax treaty benefits. （1）非居民纳税人是否对所得或所得据以产生的财产或权利具有控制权或处置权？Does the non-resident taxpayer have control over
15、 or the right to dispose of the income or the property or rights from which such income derives? 是 Yes 否 No （2）非居民纳税人是否对所得或所得据以产生的财产或权利承担相应风险？Does the non-resident taxpayer bear the risks associated with the income or the property or rights from which such income derives? 是 Yes 否 No （3）非居民纳税人据以取得该项所
16、得的有关权利或财产是否为获得税收协定的减免税利益而安排？With respect to the property or rights from which the non-resident taxpayer derives the income, have arrangements been made in such 是 Yes 否 No a way so as to gain access to the treaty benefits of tax exemption or reduction?（4）声明： Declaration:我谨声明，我为该项所得的受益所有人，我取得该项所得的有关权利
17、并非为了获得税收协定利益而安排。I hereby declare that I am the beneficial owner of the income, and arrangements have not been made, with repect to the rights from which the income derives, for the purpose of gaining tax treaty benefits.非居民纳税人签章或签字 年 月 日Seal or signature of non-resident taxpayer Y M D11享受税收协定待遇的优惠税率
18、（或实际征收率） Preferential tax rate under tax treaty (or actual tax rate)四、税务机关管理采集信息IV. Information for Use by Tax Authorities（一）享受利息条款待遇(I) Claiming Tax Treaty Benefits under the Article of Interest12贷款合同利率Interest rate for loan contract 同期市场利率Market interest rate of the same period还款条件Repayment terms
19、13非居民纳税人与利息支付人之间是否有关联关系？Is there any related party relationship between non-resident taxpayer and interest payer? 是 Yes 否 No 14在利息据以产生和支付的贷款合同之外，非居民纳税人与第三人之间是否存在在数额、利率和签订时间等方面相近的其他贷款或存款合同?Apart from the loan agreement in respect of 是 请在下一题中说明Yes. Please specify in the next question 否 Nowhich interes
20、t arises and is paid, are there any other loan or deposit contracts between the non-resident taxpayer and a third party which are similar in terms of the amount, interest rate, date of signing and other aspects? *15请简要说明非居民纳税人与第三人之间合同情况（包括第三人名称、第三人与非居民纳税人的关系、合同签约日期、金额、期限、利率、付息与还款条件、担保人等）Please give
21、a brief account of the contract(s) entered into between the non-resident taxpayer and the third party (including the name of the third party, the relationship between the non-resident taxpayer and the third party, date of contract signing, contract amount, contract period, interest rate, interest an
22、d principal repayment terms, guarantor, etc.).(二)享受特许权使用费条款待遇(II) Claiming Tax Treaty Benefits under the Article of Royalties16对据以收取特许权使用费的权利或财产，非居民纳税人是否拥有权属证明?如有，可另附权属证明材料。Does the non-resident taxpayer have an ownership certificate with respect to the rights or property from which the royalties de
23、rive? If so, the copy of the certificate may be attached separately. 是 Yes 否 No 17非居民纳税人与特许权使用费支付人之间是否有关联关系？Is there a related party relationship between non-resident taxpayer and royalty payer? 是 Yes 否 No 18在特许权使用费据以产生和支付的版权、专利、技术等使用权转让合同之外，非居民纳税人与第三人之间是否存在在有关版权、专利、技术的使用权或所有权方面的转让合同？ Apart from tra
24、nsfer agreement under which the right to use copyright, patent, technology or other rights arises and under which the royalty is paid, are there any other transfer agreements, between the non-resident taxpayer and a third party, concerning the right to use or ownship of related copyright, patent, te
25、chnology or other 是 请在下一题中说明 Yes. Please specify in the next question 否 Norights?*19请简要说明非居民纳税人与第三人之间合同情况（包括第三人名称、第三人与非居民纳税人的关系、合同签约日期、金额、期限、受让使用条件、收费方式等）Please give a brief account of the contract(s) entered into between the non-resident taxpayer and the third party (including the name of the third
26、 party, the relationship between the non-resident taxpayer and the third party, date of contract signing, contract amount, contract period, conditions of use by licensee, manner in which fees are to be paid, etc.).(三) 其他信息(III) Other Information20非居民纳税人是否有义务在收到所得的 12个月内将所得的全部或绝大部分（60%以上）支付或派发给第三国（地区
27、）居民?Is the non-resident taxpayer obligated to pay or distribute all or most of (above 60% thereof) the income to residents of a third state (region) within 12 months after the receipt of the income? 是 请填写下面 2题Yes. Please fill in the following two questions 否 No收款方名称Name of recipient收款方居民国（地区）Residen
28、t state (region) of recipient支付比例Payment percentage支付时间Time of payment*21非居民纳税人在取得该项所得后的 12个月内有义务对外支付或派发的情况Non-resident taxpayer is obligated to pay or distribute the income within 12 months after receipt*22请简要说明对该项所得进行上述处理的理由Please briefly account for the above treatment of the income. 23缔约对方国家（地区）
29、对此项所得的税收处理情况Tax treatment of the income in the other contracting party.不征税 免税 征税税率小于等于 12.5% 其他Not liable to tax Exempt Tax rate less than or equal to 12.5% Others *24如果非居民纳税人通过代理人取得该项所得，请填写以下问题 If non-resident taxpayer earns the income through an agent, please provide the following information.（1）受
30、托投资方或代理人名称Name of agent or entrusted investor（2）受托投资方或代理人收费标准和条件Standard service charge and terms of agency or entrusted investment relationship（3）与委托投资或代理相关的风险和收益是否由非居民纳税人承担？Does the non-resident taxpayer assume the risks and enjoy the benefits in relation to the assets held and income passing via
31、the agent? 是 Yes 否 No （4）请简要说明委托投资或代理关系双方的权利和义务。Please briefly account for the right and obligations of both parties in the agency or entrusted investment relationship.25非居民纳税人近三年是否有来源于中国境内其他地区的同类所得？Has the non-resident taxpayer received any income of the same type sourced in other regions within Ch
32、ina over the past three years? 是 Yes 否 No *26非居民纳税人近三年是否就来源于中国境内其他地区的同类所得享受过税收协定待遇？ Has the non-resident taxpayer claimed tax treaty benefits for the income of the same type 是 Yes 否 No sourced in other regions within China over the past three years?*27请说明非居民纳税人近三年就来源于中国境内其他地区的同类所得享受税收协定待遇的情况Please i
33、ndicate the details of any tax treaty benefits claimed by the non-resident taxpayer for the same type of income sourced in other regions within China over the past three years.主管税务机关In-charge tax authority时间(年份)Time (year)所得金额Amount of income减免税金额Amount of tax reduction or exemption（1） （2） （3） （4） （
34、5） 五、附报资料清单V. List of Documents Attached28非居民纳税人自行选择提供的能够证明其符合享受协定待遇的其他资料清单List of other documents provided by the non-resident taxpayer on a voluntary basis to justify entitlement to tax treaty benefits（1） （2） （3） （4） （5） 29非居民纳税人以前已提交而此次可以免于重复提交的资料清单和提交时间 List of documents submitted before (and ne
35、ed not to be resubmitted) / Date of submission（1） 提交时间Date of submission（2） 提交时间Date of submission（3） 提交时间Date of submission（4） 提交时间Date of submission（5） 提交时间Date of submission六、备注VI. Additional Notes七、声明VII. Declaration我谨声明以上呈报事项真实、准确、无误。I hereby declare that the information given above is true, ac
36、curate and error-free.非居民纳税人签章或签字 年 月 日Seal or signature of non-resident taxpayer Y M D 扣缴义务人公章：Seal of the withholding agent: 代理申报中介机构公章：Seal of the tax agent:主管税务机关受理专用章：Dedicated seal of the in-charge tax authority:经办人：Signature of the case handler:经办人：Signature of the case handler:受理人：Received by:填表日期： 年 月 日Date of filing: Y M D申报日期： 年 月 日Date of filing: Y M D 受理日期： 年 月 日Date of case acceptance: Y M D国家税务总局监制
