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KEMENTERIAN KEUANGAN REPUBLIK INDONESIA

DIREKTORAT JENDERAL PAJAK

PERATURAN DIREKTUR JENDERAL PAJAK

NOMOR PER- 40 /PJ/2010

TENTANG

PENGEMBALIAN KELEBIHAN PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK TERUTANGBAGI WAJIB PAJAK LUAR NEGERI

DIREKTUR JENDERAL PAJAK,

Menimbang : a . bahwa berdasarkan ketentuan Pasal 32A Undang-Undang Nomor 7 Tahun 1983tentang Pajak Penghasilan sebagaimana telah beberapa kali diubah terakhir denganUndang-Undang Nomor 36 Tahun 2008 diatur bahwa pemerintah berwenang untukmelakukan perjanjian dengan pemerintah negara lain dalam rangka penghindaranpajak berganda dan pencegahan pengelakan pajak ;

b. bahwa dalam rangka melaksanakan ketentuan Pasal 9 Peraturan Menteri KeuanganNomor 190/PMK .03/2007 tentang Tata Cara Pengembalian Kelebihan PembayaranPajak Yang Seharusnya Tidak Terutang,

bahwa berdasarkan pertimbangan sebagaimana dimaksud dalam huruf a dan hurufb, perlu menetapkan Peraturan Direktur Jenderal Pajak tentang PengembalianKelebihan Pembayaran Pajak Yang Seharusnya Tidak Bagi Wajib Pajak LuarNegeri ;

Mengingat : 1 . Undang-Undang Nomor 6 Tahun 1983 tentang Ketentuan Umum dan Tata CaraPerpajakan (Lembaran Negara Republik Indonesia Tahun 1983 Nomor 49,Tambahan Lembaran Negara Republik Indonesia Nomor 3262) sebagaimana telahbeberapa kali diubah terakhir dengan Undang-Undang Nomor 16 Tahun 2009(Lembaran Negara Republik Indonesia Tahun 2009 Nomor 62, TambahanLembaran Negara Repulbik Indonesia Nomor 4999) ;

2 . Undang-Undang Nomor 7 Tahun 1983 tentang Pajak Penghasilan (LembaranNegara Republik Indonesia Tahun 1983 Nomor 50, Tambahan Lembaran NegaraRepublik Indonesia Nomor 3263) sebagaimana telah beberapa kali diubah terakhirdengan Undang-Undang Nomor 36 Tahun 2008 (Lembaran Negara RepublikIndonesia Tahun 2008 Nomor 133, Tambahan Lembaran Negara RepublikIndonesia Nomor 4893) ;

3 . Peraturan Menteri Keuangan Nomor 188/PMK.03/2007 tentang Tata CaraPengembalian Kelebihan Pembayaran Pajak ;

4 . Peraturan Menteri Keuangan Nomor 190/PMK.03/2007 tentang Tata CaraPengembalian Kelebihan Pembayaran Pajak Yang Seharusnya Tidak Terutang ;

MEMUTUSKAN :

Menetapkan : PERATURAN DIREKTUR JENDERAL PAJAK TENTANG PENGEMBALIANKELEBIHAN PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK TERUTANG BAGIWAJIB PAJAK LUAR NEGERI

4

Pasal 1

Dalam Peraturan Direktur Jenderal Pajak ini yang dimaksud dengan :

1 . Persetujuan Penghindaran Pajak Berganda yang selanjutnya disebut P3B adalahperjanjian antara Pemerintah Indonesia dengan pemerintah negara/jurisdiksi laindalam rangka penghindaran pajak berganda dan pencegahan pengelakan pajak .

2. Wajib Pajak luar negeri selanjutnya disebut WPLN adalah subjek pajak luar negerisebagaimana dimaksud dalam Undang-Undang Nomor 7 Tahun 1983 tentang PajakPenghasilan sebagaimana telah beberapa kali diubah terakhir dengan Undang-Undang Nomor 36 Tahun 2008 .

3 . Pemotong/Pemungut Pajak adalah badan pemerintah, subjek pajak dalam negeri,penyelenggara kegiatan, bentuk usaha tetap, atau perwakilan perusahaan luarnegeri lainnya yang diwajibkan untuk melakukan pemotongan atau pemungutanpajak atas penghasilan yang diterima atau diperoleh WPLN sesuai ketentuan yangberlaku, termasuk P3B .

4 . Pajak Yang Seharusnya Tidak Terutang adalah pajak atas penghasilan yangditerima atau diperoleh WPLN yang seharusnya tidak dipotong atau dipungut olehPemotong/Pemungut Pajak sesuai dengan ketentuan yang berlaku, termasuk P3B .

5 . Pejabat Yang Berwenang adalah pejabat yang berwenang sebagaimana dimaksuddalam P3B .

6 . Prosedur Persetujuan Bersama atau Mutual Agreement Procedures selanjutnyadisebut MAP adalah prosedur yang dijalankan oleh Pejabat Yang Berwenang akibatpenerapan P3B yang tidak sebagaimana mestinya sesuai dengan ketentuan yangdiatur dalam P3B .

7 . Kesepakatan Dalam Rangka MAP (mutual agreement) adalah kesepakatan antaraPejabat Yang Berwenang dari Indonesia dan Pejabat Yang Berwenang dari negaramitra P3B dalam rangka menjalankan MAP sesuai dengan ketentuan yang diaturdalam P3B .

8 . Surat Keterangan Domisili yang selanjutnya disebut SKD adalah formulir Certificateof 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 PelayananPajak tempat Pemotong/Pemungut Pajak terdaftar sebagai Wajib PajakPemotong/Pemungut Pajak .

10 . Surat Pemberitahuan Masa yang selanjutnya disebut SPT Masa adalah SuratPemberitahuan yang digunakan oleh Pemotong/Pemungut Pajak untuk melaporkanpenghitungan dan penyetoran atas pemotongan atau pemungutan pajak yang telahdilakukan untuk suatu Masa Pajak tertentu sesuai dengan ketentuan yang berlaku .

Pasal 2

Pajak Yang Seharusnya Tidak Terutang atas penghasilan yang diterima atau diperolehWPLN meliputi :

a . kesalahan pemotongan atau pemungutan pajak yang mengakibatkan pajak yangdipotong atau dipungut oleh Pemotong/Pemungut Pajak lebih besar daripada pajakyang 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 seharusnyaberdasarkan ketentuan yang diatur dalam P3B sesuai dengan Kesepakatan Dalam

Rangka MAP .

Pasal 3

(1) Wajib Pajak yang dapat mengajukan permohonan pengembalian kelebihanpembayaran Pajak Yang Seharusnya Tidak Terutang sebagaimana dimaksuddalam Pasal 2 adalah WPLN yang tidak menjalankan kegiatan atau usaha melaluibentuk usaha tetap di Indonesia .

(2) Permohonan sebagaimana dimaksud pada ayat (1) harus diajukan oleh WPLNmelalui Pemotong/Pemungut Pajak .

Pasal 4

(1) Permohonan sebagaimana dimaksud dalam Pasal 3 ayat (1) harus memenuhipersyaratan sebagai berikut :

a. diajukan secara tertulis kepada Direktur Jenderal Pajak melalui Kepala KPPdengan menggunakan Form-DGT 3 sebagaimana ditetapkan dalam Lampiran IPeraturan 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 PajakYang Tidak Seharusnya Terutang, sehingga tidak dipertimbangkan .

Pasal 5

Pemotong/Pemungut Pajak harus menyampaikan permohonan WPLN yang telahmemenuhi persyaratan sebagaimana dimaksud dalam Pasal 4 kepada Kepala KPP .

Pasal 6

Surat kuasa sebagaimana dimaksud pada Pasal 4 ayat (1) huruf c harus dibuat olehWPLN dengan memenuhi syarat-syarat sebagai berikut :

a . menggunakan Form-DGT 4 sebagaimana ditetapkan dalam Lampiran II PeraturanDirektur 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

(1)

perundang-undangan perpajakan yang berlaku .

5) mencantumkan pernyataan pemberian kuasa kepada Pemotong/PemungutPajak untuk menyampaikan permohonan pengembalian kelebihan pembayaranPajak Yang Seharusnya Tidak Terutang beserta kelengkapannya ke KPP danbertindak mewakili WPLN untuk menerima pengembalian kelebihanpembayaran Pajak Yang Seharusnya Tidak Terutang .

Pasal 7

Dokumen pendukung sebagaimana dimaksud dalam Pasal 4 ayat (1) huruf d terdiridari :

a. SKD dengan menggunakan Form-DGT 5 sebagaimana ditetapkan dalamLampiran III Peraturan Direktur Jenderal Pajak ini ;

b. bukti pemotongan/pemungutan pajak asli yang dimintakan pengembaliankelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang ;

c . surat pernyataan WPLN bahwa pajak yang dimintakan pengembalian belumdiperhitungkan dengan pajak WPLN yang terutang di luar negeri dan/atau belumdibebankan sebagai biaya dalam penghitungan penghasilan kena pajak WPLNdi luar negeri ;

d . dalam hal WPLN adalah subjek pajak dalam negeri dari negara/jurisdiksi mitraP3B Indonesia dan menerima atau memperoleh penghasilan yang pasal terkaitdalam P36 memuat klausul beneficial owner, yaitu :

1) nama, alamat, kewarganegaraan, dan informasi rinci mengenai dewandireksi ;

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 dariIndonesia; dan

7) laporan keuangan dan surat pemberitahuan pajak untuk tahun yangmencakup 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 bahwapemohon 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 usahadi Indonesia melalui suatu bentuk usaha tetap ; dan

c) surat keterangan dari Pemotong/Pemungut Pajak mengenai lamanyapelaksanaan 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 dariperusahaan 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 menerangkanalasan pemotongan pajak atas branch profit ;

8) penghasilan Iainnya :

a) pernyataan Pemotong/Pemungut Pajak bahwa WPLN adalah pemilik sahatas penghasilan ; dan

b) penjelasan WPLN mengenai substansi penghasilan ; dan

f . dokumen lain yang menurut WPLN atau Pemotong/Pemungut Pajak perludisampaikan kepada Direktur Jenderal Pajak .

(2) Form-DGT 5 sebagaimana dimaksud pada ayat (1) huruf a hanya dipersyaratkanbagi WPLN yang merupakan subjek pajak dalam negeri di negara/jurisdiksi mitraP3B 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 tangansesuai dengan kelaziman di negara/jurisdiksi mitra P3B ;

c . telah disahkan oleh Pejabat Yang Berwenang, wakilnya yang sah, atau pejabatkantor pajak yang berwenang di negara/jurisdiksi mitra P3B, yang dapat berupatanda tangan atau diberi tanda yang setara dengan tanda tangan sesuai dengankelaziman di negara/jurisdiksi mitra P3B; dan

d . dalam hal WPLN tidak dapat memperoleh pengesahan Pejabat Yang Berwenangdi negara/jurisdiksi mitra P3B pada Form-DGT-5 sebagaimana dimaksud padahuruf c, pengesahan dimaksud dapat digantikan dengan surat keterangandomisili asli yang lazim disahkan atau diterbitkan oleh negara/jurisdiksi mitra P3Bdengan 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 denganPajak Yang Seharus Tidak Terutang ; dan

4

(3)

(1)

4) mencantumkan tanda tangan Pejabat Yang Berwenang, wakilnya yang sah,atau pejabat kantor pajak yang berwenang di negara mitra P3B atau tandayang setara dengan tanda tangan sesuai dengan kelaziman dinegara/jurisdiksi mitra P3B dan nama pejabat dimaksud .

Dalam hal permohonan WPLN terkait dengan pelaksanaan Kesepakatan DalamRangka MAP sebagaimana dimaksud dalam Pasal 2 huruf c, dokumen pendukungsebagaimana dimaksud dalam Pasal 4 ayat (1) huruf d terdiri dari :

a. bukti pemotongan/pemungutan pajak asli yang dimintakan pengembaliankelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang ; dan

b. fotokopi surat Kesepakatan Dalam Rangka MAP .

Pasal 8

Dalam rangka menyelesaikan permohonan WPLN, Direktur Jenderal Pajak melaluiKepala KPP :

a . melakukan penelitian atas permohonan pengembalian kelebihan pembayaran PajakYang Seharusnya Tidak Terutang ;

b. dapat meminta keterangan dari Pemotong/Pemungut Pajak, WPLN, Pejabat YangBerwenang di negara mitra P3B, dan/atau pihak lain .

Pasal 9

Permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya TidakTerutang ditolak dalam hal berdasarkan hasil penelitian sebagaimana dimaksuddalam Pasal 8 huruf a :

a. WPLN merupakan subjek pajak dalam negeri Indonesia ;

b . pajak yang dipotong atau dipungut belum disetor oleh Pemotong/PemungutPajak ;

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 kenapajak 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 mengenaipencegahan penyalahgunaan P3B ; atau

f . pajak yang dipotong atau dipungut oleh Pemotong/Pemungut Pajak telah sesuaidengan ketentuan yang berlaku, termasuk P3B .

(2) Permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya TidakTerutang terkait dengan pelaksanaan Kesepakatan Dalam Rangka MAPsebagaimana dimaksud dalam Pasal 2 huruf c ditolak dalam hal berdasarkanpenelitian sebagaimana dimaksud dalam Pasal 8 huruf a :

a. pajak yang dipotong atau dipungut belum disetor oleh Pemotong/PemungutPajak; atau

b . jumlah kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang menurutpermohonan WPLN Iebih besar daripada jumlah kelebihan pembayaran PajakYang Seharusnya Tidak Terutang berdasarkan Kesepakatan Dalam RangkaMAP .

k

(3) Permohonan WPLN yang bukan berasal dari negara/jurisdiksi mitra P3B Indonesiaditolak dalam hal berdasarkan hasil penelitian sebagaimana dimaksud dalam Pasal8 huruf a :

a. WPLN merupakan subjek pajak dalam negeri Indonesia ;

b . pajak yang dipotong atau dipungut belum disetor oleh Pemotong/PemungutPajak ;

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 pajakWPLN 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 olehPemotong/Pemungut Pajak, Kepala KPP menagih pajak yang terutang kepadaPemotong/Pemungut Pajak sesuai ketentuan yang berlaku .

(5) Dalam hal SPT Masa belum dilaporkan oleh Pemotong/Pemungut Pajak, KepalaKPP harus menindaklanjutinya sesuai ketentuan yang berlaku .

Pasal 10

(1) Setelah melakukan penelitian sebagaimana dimaksud dalam Pasal 8 huruf a, KepalaKPP atas nama Direktur Jenderal Pajak menerbitkan Surat Ketetapan Pajak LebihBayar atas nama Pemotong/Pemungut Pajak q.q . WPLN, apabila terdapat PajakYang Seharusnya Tidak Terutang, paling lama 3 (tiga) bulan sejak permohonanWPLN diterima secara lengkap .

(2) Dalam hal permohonan WPLN ditolak, Direktur Jenderal Pajak melalui Kepala KPPharus memberitahukan secara tertulis kepada WPLN melalui Pemotong/PemungutPajak paling lama 3 (tiga) bulan sejak permohonan WPLN diterima secara lengkapdan 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 KeputusanPengembalian Kelebihan Pembayaran Pajak atas nama Pemotong/Pemungut Pajakq .q. WPLN sesuai dengan ketentuan yang berlaku .

(4) Atas dasar Surat Keputusan Pengembalian Kelebihan Pembayaran Pajaksebagaimana dimaksud pada ayat (3), Kepala KPP atas nama Menteri Keuanganmenerbitkan Surat Perintah Membayar Kelebihan Pembayaran Pajak atas namaPemotong/Pemungut Pajak q .q . WPLN sesuai dengan ketentuan yang berlakudengan mencantumkan nomor rekening bank yang berada di Indonesia milikPemotong/Pemungut Pajak dan dengan menggunakan mata uang Rupiah .

Pasal 11

Pada saat berlakunya Peraturan Direktur Jenderal Pajak ini, Surat Edaran DirekturJenderal Pajak Nomor SE-09/PJ .10/1994 tentang Restitusi Pajak Penghasilan Pasal 26Sehubungan Dengan Ketentuan Dalam PPPB dinyatakan tidak berlaku, kecuali untukpermohonan pengembalian Pajak Penghasilan Pasal 26 dalam rangka penerapanketentuan P3B yang telah diajukan oleh WPLN sebelum berlakunya Peraturan DirekturJenderal Pajak ini .

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Pasal 11

Peraturan Direktur Jenderal Pajak ini mulai berlaku pada tanggal ditetapkan .

Ditetapkan di Jakartapadatanggal 9 Agust us 2010

ND TJIPTARDJO4281975121002

MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIADIRECTORATE GENERAL OF TAXES

APPLICATION FORMFOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 3)

to claim refund for the following tax withheld in Indonesia : (additional paper may be used) (8)

1 .

2 .

3 .

4 .

Withholding Tax Slip (No. and Dat(A)

Total

Tax Withheld (Rupiah

(B)

Tax Refund Claimed (Rupiah(C)

The above tax as mentioned in column B withheld by Indonesia withholding tax agent :

Name

( 9)

Taxpayer ID number

( 10 )

Address

(11)

Reasons of refund claim : (additional paper may be used) (12)

Lampiran IPeraturan Direk(urJenderal Pajak

Nomor PER-L~o

/PJ/2010TENTANG PENGEMBALIAN KELEBIHAN

PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAKTERUTANG BAGI WAJIB PAJAK LUAR NEGERI

Documents attached : (13) •)

•

Power of Attorney (completed Form-DGT 4)•

Certificate of Domicile (completed Form-DGT 5) (required only if claimant is resident of Indonesian DTC partner)

•

Original withholding tax slip(s) :piece(s)

•

Documents to support the statement of beneficial ownership, which consists of 7 items . (required only if claimant is resident ofIndonesian 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'scountry/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)

Signature of the claimant or individual

Capacity in which acting (16)

) Please check the appropriate boxauthorized to sign for the claimant (15)

FORM-DGT 3

4

Name

I the undersigned :(1)

Address (2)

Phone No. (_)

acting as : ) O the claimant himself-individual O the claimant himself-management of non individual entity (3)

Information

Name

of the claimant :

(4)

Taxpayer ID No . (5)

Address (6)

Phone No.(_)

Country/jurisdiction (7)

9 .

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 byIndonesia withholding tax agent may claim tax refund tothe Director General of Taxes, in case :

a . the non resident considers that the tax withheld is notin accordance with Indonesian income tax law and/orDouble Taxation Convention/Agreement (DTC)concluded by Indonesia and his domicile country/jurisdiction, or

b . the non resident claims tax refund as the agreedresult of Mutual Agreement Procedures conducted bythe Competent Authorities of Indonesia and of treatypartner .

2 . The application must be made by non resident taxpayerwho claims the refund ("the Claimant") and must besubmitted through the Indonesia withholding tax agent .

3 . One application must be made for any tax claims relatedto one withholding tax agent .

4. The Claimant must grant a specific power of attorney tothe withholding tax agent to lodge the application to theDirector General of Taxes and to provide a bank accountwhich will be used to transfer the approved tax refund .

5 . Documents and information that are required to beprovided by the Claimant (please read the relatedinstructions 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 residentof the Indonesia DTC partner),

d . The withholding tax slips (original),

e . The Claimant statement that the tax claimed has notbeen utilized to reduce the liable tax nor to deduct thetaxable income in calculating the liable tax in theclaimant's country/jurisdiction,

f. Specific documents related to the earned income,

Specific documents/information to support thebeneficial ownership statement, which is only requiredif the Claimant is resident of Indonesia DTC partnerand the related article(s) in DTC mentions thebeneficial owner phrase .

6 . Director General of Taxes shall give a decision not morethan 3 (three) months since the application is lodgedcompletely. Should the application is refused ; a writtennotification will be sent to the Claimant through thewithholding tax agent.

7 . An Overpayment Tax Assessment Letter (SKPLB) will beissued for approved claim to process the refund transfer tothe withholding tax agent's bank account . For transferringany tax refund, it is required a bank account, Rupiahcurrency, in any bank that is situated in Indonesia .

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 . Forindividual, please fill in the name of the Claimant . For nonindividual entity, please fill in the name of individual who mayact 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 .

Number 4 to 6 :This section must be filled with information of the Claimantwhose 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 numberin country/jurisdiction where the claimant registered as ataxpayer resident.

(6) Please fill in the Claimant's address .

(7) Please fill in the country/jurisdiction where the claimantregistered as a taxpayer resident .

Number 8 :Please fill in the column (A) with the number and date ofwithholding tax slip(s) issued by withholding tax agent, column(B) with the amount of tax withheld as stated in the withholdingtax slip (in Rupiah) and column (C) with the amount of taxclaimed (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 informationregarding Indonesia withholding tax agent . You may refer toinformation 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) ofthe 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 anyarticles of the Double Tax Convention (DTC) which relevant orrelated to the claim . The Claimant may state his reasons andarguments to support that the tax withheld is not in accordancewith the Indonesian income tax law and/or the DTC . Additionalpaper may be used by the claimant .

Number 13 :

Please check the appropriate box to declare that the Claimanthas completed all the requirements .

Notes : The failure to present the following attachment willcause the Director General of Taxes to refuse the application .

a . Power of Attorney (completed Form-DGT 4) . The formis downloadable at http://www.paiak .cio .i d . The Claimantmust provide a specific power of attorney to grant power tothe withholding tax agent to submit the application and toprovide a bank account number . This document is liable toIndonesian stamp duty (IDR 6,000) according to the LawNo. 13 Year 1985 .

b . Certificate of Domicile (completed Form-DGT 5) . Theform is downloadable at http://www .paiak.go .i d . This formis required to be submitted for the application of the DTC .The form of certificate of domicile, issued by theDirectorate General of Taxes and must be filledcompletely and signed by the Claimant. The first page ofthis certificate must be authorized by the CompetentAuthorities, his representative or authorized tax office incountry/jurisdiction where the Claimant is registered as ataxpayer resident . In case the competent authority, hisauthorized representative, or the authorized tax officecannot put his authorization in this form, the Claimant maysubmit the certificate of domicile, as an attachment ofForm-DGT 5, which is usually issued in the Claimant'scountry/jurisdiction and such certificate shall meet therequirements as provided in the instruction of Form-DGT 5 .

c . Original withholding tax slip(s) . The Claimant mustprovide the original withholding tax slips to support theinformation provided in Number 8 .

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 beenutilized to reduce the liable tax nor to deduct the taxableincome in calculating the liable tax in the Claimant'scountry/jurisdiction .

e . Document(s) related to the earned income .

1) 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 ;

2) Dividend income :a) a declaration of dividend distribution issued by

the Indonesian entity who paid the dividend,

b) the bank statement that showing the receipt andthe use of income, and

c) a statement letter made by the company whodistributed the dividend mentioning that theclaimant is the rightful owner of dividend ;

3) Royalties, rent and other income related to theuse of or for the right to use asset, property orequipment:

a) the related agreement,b) the recording journal of the receipt of income,

c) the bank statement that showing the receipt andthe use of income, and

d) a notice of income computation ;4) Income from services, rendered by individual or

non individual :

a) the related service agreement;

b) a statement letter made by the claimantmentioning that claimant conducted business oractivities in Indonesia not through a permanentestablishment,

c) a statement letter issued by the Indonesianwithholding tax agent mentioning that theclaimant rendered services in Indonesia for aperiod not more than the period stipulated in theDTC to constitute a permanent establishment ;

5) Gains from the alienation of shares :

a) the agreement related to the alienation of sharesof a company situated in Indonesia,

b) Notary deed on transfer of right of the alienatedshares .

6) Insurance or reinsurance premium :

a) the insurance policy, and

b) a notice of premium computation ;7) branch profit of a permanent establishment :

a) the insurance policy,b) the annual income tax return of the related

permanent establishment that situated inIndonesia,

c) a statement letter issued by the permanentestablishment who acts as the withholding taxagent concerning the ground of the taxwithholding .

8) Other income :

a) a statement letter issued by the Indonesianwithholding tax agent mentioning that theClaimant is the rightful owner of the income ;

b) a description by the claimant regarding thesubstance of income, including the underlyingtransaction .

f . Documents to support the statement of beneficialownership

9 .

These documents are required to be submitted by theclaimant who is a resident in country/jurisdiction that hasconcluded DTC with Indonesia and the related article inDTC mentions the beneficial owner phrase .

To support that the Claimant is the beneficial owner of theincome, the following information (7 items) must beprovided as attachment of the application (completedForm-DGT 3) :1)

Name, address, nationality and other detailedinformation of board of directors ;

2)

Name, address, shares and other detailedinformation concerning the shareholders ;

3)

Number of employees and detailed job description ;

4)

Description of investment which generates theincome related to the tax claimed ;

5)

Financial sources of the investment ;

6)

The use or the plan of use of income generated bythe investment ;

7) The Claimant's financial statements and reportedincome tax return for year when the paymentoccured and for the 2 (two) years before .

Other documents

The Claimant or the withholding tax agent may attachdocuments other than the required documents mentionedabove to support the claim .

Notes :

a . In case the tax claimed by the Claimant is resulted frommutual agreement agreed by both Competent Authoritiesthrough a Mutual Agreement Procedures, the claimant isonly 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 isproduced by both Competent Authorities inconducting the Mutual Agreement Procedures

b . In case the Claimant is not a resident taxpayer of acountry/jurisdiction which has concluded DTC withIndonesia, the Claimant is only required to submit thefollowing documents :

1) Power of Attorney (completed Form-DGT 4),

2) Original withholding tax slip(s),

3) The Claimant statement that the tax claimed has notbeen utilized to reduce the liable tax nor to deduct thetaxable income in calculating the liable tax in theClaimant's country/jurisdiction, and

4) Document(s) related to the earned income asmentioned in No .13 .d .

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 representativewho signs this form .

I

The undersigned :

NameAddress

FORM•DGT 4


POWER OF ATTORNEYFOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 4)

Phone No .( )

acting as *) : O the claimant (for Individual)

(3)

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 receivethe 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) (13) (14)

Signature of the proxy

Signature of the claimant or individual

Capacity in which actingauthorized to sign on behalf of the claimant

*) Please check the appropriate box .

Lampiran IIPeraturan Direktur Jenderal Pajak

Nomor PER- L~O /PJ/2010TENTANG PENGEMBALIAN KELEBIHAN


17 the claimant (representative of non individual entity)

Information of the claimant :

Name (4)


Address (6)

Phone No.(_)Country/Jurisdiction : (7)

herewith gives the power of attorney to (Indonesia withholding tax agent) :

Name (8)


Address (10)

INSTRUCTIONS

FOR FORM OF POWER OF ATTORNEY (FORM-DGT 4)

General information :

This form is one of the required documents which granting apower of attorney to Indonesia withholding tax agent to lodgethe refund application (completed Form-DGT 3) and allrequired attachments and to act on behalf the Claimant toreceive any tax refund approved by the Director General ofTaxes .

It is required to provide an account in any bank situated inIndonesia in Indonesia Rupiah (IDR) currency.

Guidance to fill this form :

Number 1 :Please fill in the name of individual who signs this form . Forindividual, please fill in the name of the Claimant . For nonindividual entity, please fill in the name of individual who mayact as the representative of the entity .

Number 2 :Please fill in the address of individual who will sign the powerof attorney.

Number 3 :

Please check the appropriate box .

Number 4 :Please fill in the Claimant's name . If the Claimant is anindividual, the name is as it is filled in Number 1 .

Number 5 :Please fill in the Claimant's taxpayer identification number incountry/jurisdiction where the claimant registered as a taxpayerresident .

Number 6 :Please fill in the claimant's address .

Number 7 :Please fill in the country/jurisdiction where the claimantregistered as a taxpayer resident .

Number 8-10 :Please fill in the information of Indonesia withholding tax agentwho receives the power of attorney . The information may beappeared 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 thisform .

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 . Incase the signor is the representative, please fill in the capacityof the signor .

Note :

The Power of Attorney is liable to Indonesian stamp duty (IDR6,000) according to Law No . 13 Year 1985 .

i

J


CERTIFICATE OF DOMICILE OF NON RESIDENTFOR 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 theIndonesia 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 aresident 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 theclaimant, 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 orjurisdiction where the claimant is a taxpayer resident .

(5) (full name) hereby declare that :

O1

I am (authorized to sign for) the beneficial owner of income stated in the completed Form-DGT 3 (this statement must befilled 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, andcomplete .

(9)Contact Number

CERTIFICATION BY COMPETENT AUTHORITY

AUTHORIZED TAX OFFICE

THECOUNTRY/JURISDICTION OF RESIDENCE

(12)Name and signature of the Competent Authority, hisauthorized representative or authorized tax office

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] .

This form isavailable and may be downloadedatthis website: http:/www.pajak .go .id*) Please check the appropriate box

Page 1FORM-DGT 5

Date (mm/dd/yyyy) :

//(14)

Office address :

Lamp- IIIPeraturan Direktur enderaI Pajak

Nomor PER-

/PJ/2010TENTANG PENGEMBALIAN KELEBIHAN


k

AME OF COUNTRY/JURISDICTION OF THE CLAIMANTI (1) IINFORMATION OF THE CLAIMANT

Tax ID Number (2)

(3)

(4)

Full Name

Address

Part II : DECLARATION AND STATEMENT OF BENEFICIAL OWNERSHIP BY THE CLAIMANT

(6) (7)-/-/ (8)Signature of the income recipient or individual

authorized to sign for the income recipientDate (mm/dd/yy) Capacity in which acting

W MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIADIRECTORATE GENERAL OF TAXES

CERTIFICATE OF DOMICILE OF NON RESIDENTFOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 5)

(25)

(26)

(27)

(29)

o Yes o No *)

n Yes o No *)

o Yes o No *)

o Yes D No*)

o Yes o No*)

*) 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)

//(36)

(37)

(38)Signature of the income recipient or individual

Date (mm/dd/yy)

Capacity in which acting

Contact Numberauthorized to sign for the income recipient

Page 2

FORM-DGT 5

Lampiran IIIPeraturan Direktur Jenderal Pajak

Nomor PER- 44 /PJ/2010TENTANG PENGEMBALIAN KELEBIHAN


(28)

Part IV

TO BE COMPLETED IF THE CLAIMANT IS AN INDIVIDUAL

1 . Name : (16)

2. Date of birth (mm/dd/yyyy)

(17) 3 . Are you acting as an agent or a nominee? n Yes D No *) (18)

4. Full address :(19)

5. Do you have a permanent home in Indonesia? o Yes o No ~ (20)

6. Country where you reside ordinarily : (21)

7. Have you ever been resided in Indonesia? o Yes o No*) If so, in what period?

/

/ to /

/ (22)

And, please provide the address

(23)8 . Do you have any office, or other place of business in Indonesia? El 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?

o Yes o No *) (24)

Part V

TO BE COMPLETED IF THE CLAIMANT IS A NON INDIVIDUAL

Country of registration/incorporation :

Country where the place of management or control reside :

Address of Head Office :

Address of branches, offices, or other place of business in Indonesia (if any) :

Nature of business (Pension Fund, Insurance, Bank, Financing, etc .)

Is the entity acting as an agent or a nominee?

(30)

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

(31)

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

independent discretion .

(33)

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

INSTRUCTIONSFOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA

TAX WITHHOLDING (FORM-DGT 5)


1 . This form is only required for the Claimant whosecountry/jurisdiction has concluded Double TaxationConvention/Agreement (DTC) with Indonesia .

2 . This form consists of 2 (two) pages . The first page consistsof the Claimant declaration and authorization by theCompetent Authority or authorized tax office in theClaimant's country/jurisdiction concerning the status of theClaimant's residency .

After the Claimant fills this form completely please bring thefirst page to the competent authority or authorized tax officefor authorization .

In case the competent authority or the authorized tax officecannot put his authorization in this form, the Claimant maysubmit the certificate of domicile, as an attachment of Form-DGT 5, which is usually issued in the Claimant'scountry/jurisdiction and such certificate shall meet therequirements 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 periodwhen the income, related to the tax claimed, is derived ;and

d . It bears the signature and the name of the competentauthority, his authorized representative or theauthorized tax officer .

The second page consists of information related to theClaimant which is required to be signed by the Claimant .Authorization by the competent authority or authorized taxoffice is not necessary for information in this second page .


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 incountry where the Claimant is registered as a resident taxpayer .Please type "n .a ." in case the country/jurisdiction of the Claimantdoes not provide taxpayer identification number for residenttaxpayers .

Number 3 :Please fill in the Claimant's name .

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 onbehalf the Claimant .

If the Claimant is not an individual, this form must be filled byindividual who may act as representative of the non individualentity .

If the Claimant is an individual, please fill in the name as statedin Number 3 .

Important :

The Claimant is required to state :

a . whether the Claimant is the beneficial owner of income . Thephrase beneficial owner is commonly contained in article ofDTC related to the income of dividend, interest, royaltiesand capital gain (sometimes) . It is highly recommended tothe Claimant to check article in DTC related to the income .

In case the Claimant is not the beneficial owner, do notcheck the box;

b . whether the Claimant is the Indonesian taxpayer resident .Do not check the box if the Claimant is Indonesian residenttaxpayer .

Number 6 :The Claimant or his representative (for non individual) must signthis form .

Number 7 :Please fill in the date of signing .

Number 8 :Please fill in the capacity of the Claimant or his representativewho 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 countryof residence :

In case the Competent Authority, His authorized representativeor the authorized tax office cannot put his authorization in thisform, the Claimant may leave blank this Part . Then, the Claimantmust attach the certificate of domicile, which is commonly issuedin the Claimant's country/jurisdiction, to the completed Form-DGT 5.

Number 10 and 11 :Please fill in the name of country/jurisdiction where the Claimantis resident taxpayer.

Number 12 and 13The Competent Authorities, his authorized representative, orauthorized tax office certifies this form by signing it . The positionof the signor should be filled in Number 13 .

Number 14 :Please fill in the date when the form is signed by the competentauthority, 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 :

Please check the appropriate box . You are considered acting asan agent if you act as an intermediary or acting for and on behalfof other party in relation with the income source in Indonesia .You are considered acting as a nominee if you are the legalowner of income or of assets that the income is generated butnot 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 permanenthome is in Indonesia, you are considered as Indonesiantaxpayer resident in accordance with the Indonesian Income TaxLaw. In that case the DTC cannot be applied to the Claimant .

Number 21 :Please fill the name of country where the Claimant ordinarilyresides .

r0



Number 22 :Please check the appropriate box. In case the Claimant has everbeen resided in Indonesia, please fill the period of your stay andaddress where you resided .

Number 23 :Please check the appropriate box. In case the Claimant has anyoffices, or other place of business in Indonesia, please fill in theaddress of office or other place of business in Indonesia .

Number 24 :

Please state whether or not the Claimant's motivation instructuring the transaction related to the earned income is solelyto 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 registeredor incorporated .

Number 26 :Please fill in the country where the entity is controlled or whereits 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 placeof 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 theClaimant's facts and circumstances .

(30) Please check "No" if the entity, in relation with the earnedincome, is acting as an agent or a nominee . The meaning ofagent or nominee is mentioned in Number 18 .

(31) Please state whether or not motivation of the Claimantrelated to the earned income is solely to take advantage ofbenefit of the DTC .

(32) Please state whether or not the entity is listed in stockmarket and, if so, please type the name of the stock market .

(33) Please state whether the entity has its own management toconduct the business and such management has anindependent discretion .

(34) Please state whether the entity employs sufficient qualifiedpersonnel .

Number 35:The Claimant or his representative (for non individual) must signthis form .

Number 36:Please fill in the date of signing .



RF




1 . This form is only required for the Claimant whosecountry/jurisdiction has concluded Double TaxationConvention/Agreement (DTC) with Indonesia .

2 . This form consists of 2 (two) pages . The first page consistsof the Claimant declaration and authorization by theCompetent Authority or authorized tax office in theClaimant's country/jurisdiction concerning the status of theClaimant's residency .

After the Claimant fills this form completely please bring thefirst page to the competent authority or authorized tax officefor authorization .

In case the competent authority or the authorized tax officecannot put his authorization in this form, the Claimant maysubmit the certificate of domicile, as an attachment of Form-DGT 5, which is usually issued in the Claimant'scountry/jurisdiction and such certificate shall meet therequirements 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 periodwhen the income, related to the tax claimed, is derived ;and

d . It bears the signature and the name of the competentauthority, his authorized representative or theauthorized tax officer .

The second page consists of information related to theClaimant which is required to be signed by the Claimant .Authorization by the competent authority or authorized taxoffice is not necessary for information in this second page .


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 incountry where the Claimant is registered as a resident taxpayer .Please type "n .a ." in case the country/jurisdiction of the Claimantdoes not provide taxpayer identification number for residenttaxpayers .

Number 3 :Please fill in the Claimant's name .

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 onbehalf the Claimant.

If the Claimant is not an individual, this form must be filled byindividual who may act as representative of the non individualentity .

If the Claimant is an individual, please fill in the name as statedin Number 3 .

Important :

The Claimant is required to state :

a . whether the Claimant is the beneficial owner of income . Thephrase beneficial owner is commonly contained in article ofDTC related to the income of dividend, interest, royaltiesand capital gain (sometimes) . It is highly recommended tothe Claimant to check article in DTC related to the income .In case the Claimant is not the beneficial owner, do notcheck the box;

b . whether the Claimant is the Indonesian taxpayer resident .Do not check the box if the Claimant is Indonesian residenttaxpayer .

Number 6 :The Claimant or his representative (for non individual) must signthis form .

Number 7 :Please fill in the date of signing .



Part Ill Certification bV competent authority of the countryof residence :

In case the Competent Authority, His authorized representativeor the authorized tax office cannot put his authorization in thisform, the Claimant may leave blank this Part . Then, the Claimantmust attach the certificate of domicile, which is commonly issuedin the Claimant's country/jurisdiction, to the completed Form-DGT 5 .

Number 10 and 11 :Please fill in the name of country/jurisdiction where the Claimantis resident taxpayer .

Number 12 and 13The Competent Authorities, his authorized representative, orauthorized tax office certifies this form by signing it . The positionof the signor should be filled in Number 13 .

Number 14 :Please fill in the date when the form is signed by the competentauthority, 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 .