1、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 date: Y M D 货币单位：元人民币Currency unit:
2、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非居民纳税人中文名称Chinese name onon-resid
3、ent 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 certificate 非居民纳税人身份证件号码Number of ID certificate 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、扣缴义务人使用信息III. Information for Use
4、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 shareholing 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 capital held, directly and indirectl
5、y, 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情况Do any of the following circu
6、mstances 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 under the terms of the treaty（2）
7、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 a government or institution of
8、 the other tax treaty contracting party in circumstances in which such insured loans qualify for benefts 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 loans/funds, a guarantee or insuranc
9、e are indirectly provided by a qualified governmet 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 property do the royalties fall into?（1
10、） 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, commercial and scientific experi
11、ence（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 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 royalty income derives.(四) 其他信息 (IV)
12、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 aagent? 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D
13、eclaration 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 or the rights or property from which
14、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 or the right to dispose of the incom
15、e 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？D 是 Yes 否 No es the non-resident taxpayer bear the risks associated with the income or the property or rights from which such income derives?（3）非居民纳税人据以取得该项所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 respe
16、ct to the property or rights from which thenon-resident taxpayer derives the income, have arrangements been made in such a way so as to gain access to the treaty benefits of tax exemption or reduction? 是 Yes 否 No （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并非为了获得税收协定利益而安排。I hereby declare that
17、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（或实际征收率） Preferenial tax rate under ta
18、x 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 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
19、related party relationship between non-resident taxpayer andinterest 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 which interest arises and is paid, are there any other loan or deposit contracts between the non-resident
20、axpayer and a third party which are similar in terms of the amount, interest rate, date of signing and other aspects? 是 请在下一题中说明Yes. Please specify in the next question 否 No*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 a brief account of the contract(s) ente
21、red 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 conract signing, contract amount, contract period, interest rate, interest and principal repayment terms, guarantor,
22、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 derive? If so, the copy of the certificat
23、e 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？Ithere 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 transfer agreement under which the right to
24、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, technology or other rights? 是 请在下一题中说明 Yes.
25、 Please specify in the next question 否 No*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 party, the relationship between the non
26、-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）居民 ?Is the non-resident taxpayer oblig
27、ated to pay or distribute all or most of (above 60% thereof) the income to residents of a third state (region) within 12 mon 是 请填写下面 2 题Yes. Please fill in the hs after the receipt of the income? following two questions 否 No收款方名称Name of recipient收款方居民国（地区）Resident state (region) of recipient支付比例Paym
28、ent 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 recept*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 inome. 23缔约对方国家（地区）对此项所得的税收处理情况Tax treatment of the incom
29、e 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）受托投资方或代理人名称Name ofagent or entrusted in
30、vestor（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 enefits in relation to the assets held and income passing via the agent? 是 Yes 否 No （4）请简要说明委托投资或代理关系
31、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 China over the past three years? 是 Yes 否
32、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-residentaxpayer claimed tax treaty benefits for the income of the same type sourced in other regions within China over the past three years? 是 Yes 否 No *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 indicate the details of any tax treaty be
33、nefts 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） （5） 五、附报资料清单V. List of Documents Attached
34、28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 benefts（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 need not to be resubmitted) / Date of submi
35、ssion（1） 提交时间Date of submission （2） 提交时间Date of submission （3） 提交时间Date of sbmission（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, accurate and error-free.非居民纳税人签章或签字 年 月
36、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：Signatre 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：
37、 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【表单说明】一、本表适用于取得来源于我国的股息、利息、特许权使用费所得，需享受我国对外签署的避免双重征税协定（含与港澳避免双重征税安排）中的股息、利息、特许权使用费条款的税收协定待遇的个人所得税非居民纳税人。I. This form is applicable to non-resident individual income taxpayer who receives dividends, interest or royalties sou
38、rced in China, and claims tax treaty benefits under the article of dividends, interest or royalties of a Double Taxation Agreement (DTA) signed by China (including the DTAs with Hong Kong and Macau Special Administrative Regions).二、本表可用于自行申报或扣缴申报，也可用于非居民纳税人申请退税。非居民纳税人自行申报享受协定待遇或申请退税的，应填写本表一式两份，一份在申报
39、享受协定待遇或申请退税时交主管税务机关，一份由非居民纳税人留存；对非居民纳税人来源于中国的所得实施源泉扣缴或指定扣缴管理的，非居民纳税人如需享受税收协定待遇，应填写本表一式三份，一份交由扣缴义务人在扣缴申报时交主管税务机关，一份由扣缴义务人留存备查，一份由非居民纳税人留存。II. This form can be used for self-declaration or withholding declaration, as well as for the non-resident taxpayers application for tax refund. The non-resident t
40、axpayer initiating the self-declaration for claiming tax treaty benefits, or applying for tax refund, shall complete two copies of the form: one form is to be submitted to the in-charge tax authority at the time of such declaration or application, and the other form is to be kept by the non-resident
41、 taxpayer. Where the non-resident taxpayers China sourced income is subject to withholding tax, administered at source or by means of a designated withholding agent, and the non-resident taxpayer is entitled to tax treaty benefits, the non-resident taxpayer shall complete three copies of the form: o
42、ne is to be given to the withholding agent to submit to the in-charge tax authority at the time of the withholding declaration, one is to be kept by the withholding agent and another is to be kept by the non-resident taxpayer. 三、本表第一部分由扣缴义务人填写，如非居民纳税人自行申报纳税则无需填写。本表其余部分由非居民纳税人填写。非居民纳税人填报本表时可根据需要增加附页。
43、III. Part I of the form shall be filled in by the withholding agent, and will not be required in the case of self-declaration. The rest of the form shall be filled in by the non-resident taxpayer. When filling in the form, the non-resident taxpayer can attach separate sheets to the form if necessary
44、. 四、本表第三部分“扣缴义务人使用信息”用于在源泉扣缴情况下，扣缴义务人核对非居民纳税人是否符合享受协定待遇条件；其他部分用于税务机关采集管理信息。IV. “Information for use by withholding agent” in Part III of the form is used by a withholding agent to decide if a non-resident taxpayer is eligible for tax treaty benefits in withholding at source; the rest is for the tax
45、authority to gather information for administrative purposes.五、非居民纳税人应如实完整填写本表所列问题。如非居民纳税人没有问题所列情况，请在表格中填“无” 。本表所列选择题，请非居民纳税人在符合自身情况的选项对应的或中打勾“” 。带有*标识的题目，请具有题目所描述情况的非居民纳税人填写，与题目所描述情况不符的非居民纳税人无需填写。V. The non-resident taxpayer shall provide accurate and complete information to answer the questions con
46、tained in the form. Please write “N/A”in the form if a situation described in a question is not applicable for a non-resident taxpayer. For a multiple-choice question, please mark “” in a corresponding box (“”) or circle (“”) for a choice that fits a non-resident taxpayers situation. If a non-reside
47、nt taxpayers situation falls into the description of a question marked with “*”, answers shall be provided; otherwise, it can be skipped. 六、本表采用中英文双语制作，如中英文表述不一致，以中文为准。如无特别说明，应使用中文填写。VI. This form is prepared in Chinese and English. In case of divergence in the two languages, the Chinese text shall p
