ZS115（电子版—挂网）.docVIP

ZS115(电子版—挂网) 附件 4Annex 4 非居民享受税收协定待遇身份信息报告表（适用于个人） Personal information of non-residents claiming for treatment under Double Taxation Agreement(DTA) (for individuals) 填报日期Date　　　年　月　日Y/M/D 纳税人基本情况Taxpayers information 1在缔约对方姓名Name in the other contracting party 　 2Name in Chinese 3在缔约对方纳税识别号Tax indentification number in the other contracting party 　 4Name of family member 5与纳税人关系relationship with the taxpayer 6经常居住地habitual residence 7备注Additional information 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 构成缔约对方税收居民情况:Qualification as a fiscal resident of the other contracting party 8构成缔约对方税收居民的法律依据描述:Legal provisions prescribing the status of the taxpayer as a fiscal resident of the other contracting party 9构成缔约对方税收居民的事实情况描述: Description of facts based on which the taxpayer qualifies as a fiscal resident of the other contracting party 10在缔约对方是否保有长期居所Does the taxpayer have permanent residence in the other contracting party? 　　□是 Yes　　□否　No 11在缔约对方是否取得长期居留权Does the taxpayer have the right to permanently stay in the other contracting party　　□是 Yes　　□否 No　 12在缔约对方保有的投资额Amount of investment kept in the other contracting party 　 13最近连续12个月内在缔约对方连续或累计停留天数Number of days of continuous stay or cumulative stays in the other contracting party in the past 12 months 　 14是否保有缔约对方国籍Does the taxpayer hold nationality of the other contracting party?　　　　　　　 　□是 Yes　　□否 No 从中国取得所得在缔约对方纳税情况(限于列入税收协定适用范围的税种):Information of tax payment in the other contractiong party on the income derived from China (taxes covered by DTA only) 15税种名称Type of tax 16适用税率或税率表Effective tax rate(s) 17享受缔约对方国内减免税优惠的法律依据及条文描述Legal provisions prescribing tax deduction or exemption enjoyed in the other contracting party 　 　 　 　 　 　 　 　 　 　 　 是否构成第三方税收居民Whether a fiscal resident of a jurisdiction other than China the other contracting party 18是否在第三方负有居民纳税义务Is the taxpayer liable to tax for his worldwide income in a jurisdiction