Mu s: 02/HTQT

(Ban hnh km theo Thng t

s 28/2011/TT-BTC ngy
28/2/2011 ca B Ti chnh)

GIY NGH
KHU TR THU NC NGOI VO THU PHI NP TI VIT NAM
THEO HIP NH GIA VIT NAM V

(TN NC K KT)
KT)
(p dng cho cc t chc, c nhn l i tng c tr ca Vit Nam)
ngh nh du (x) vo trng thch hp:
A.p dng cho t chc ;

B. p dng cho c nhn; AB. p dng cho c c nhn v t chc

I.

I TNG NGH

1.

Ngi np thu:

A. T chc:
1.1.

B. C nhn:

Tn y :..............................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. CMND
B. H chiu
S: ..........................................
Ngy cp:......../......../............ ti ....................... C quan cp..................................
1.2.
Tn s dng trong giao dch
1.3.
T cch php l
A. Php nhn
B. C nhn hnh ngh c lp

A. Lin danh khng to php

B. C nhn hnh ngh ph

nhn
thuc
A.B.Khc

Nu r:.....................................
1.4. a. a ch ti Vit Nam:............
S in thoi:S Fax: E-mail: ....
a ch trn l:
A. Tr s chnh B.Nh thng tr
AB. Khc Nu r: ..............
1.4.b. a ch giao dch ti Vit Nam (nu khc vi a ch nu trn)...........
S in thoi: S Fax: E-mail: ...........
1.5.
Quc tch:
AB. Vit Nam
AB. Nc k kt
AB. Nc khc .
1.6.
M s thu ti Vit Nam (nu c): .....................................................................
1.7.a a ch ti Nc k kt:..............................................................................
S in thoi:S Fax: E-mail:...................
a ch trn l:
A.Vn phng D A. C s thng tr B.Ni lm vic B. Ni lu tr
AB. Khc Nu r: ..............
1.7.b. a ch giao dch ti Nc k kt (nu khc vi a ch nu trn)..........
S in thoi:S Fax: E-mail: ...............
1.8.
M s thu ti Nc k kt (nu c)...........................................................

2.

i din c u quyn1:

2.1.

Tn y :.........................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. CMND
B. H chiu
S: ..........................................
Ngy cp:......../......../............ ti ....................... C quan cp............................
a ch:..............................................................................................................
S in thoi:................. S Fax:............................... E-mail:.............................
M s thu (nu c):............................................................................................
T cch php l
A. Php nhn
B. C nhn hnh ngh ph thuc

A. Lin danh khng to php

AB. Khc

nhn
AB. i l thu
Nu r:..........................................

2.2.
2.3.
2.4.

II.
I TNG CHI TR THU NHP
(Trng hp nhiu i tng chi tr thu nhp, phi lp bng k km theo Giy
ngh ny vi y cc thng tin di y)
1.

2.
3.
4.

III.
1.
2.
2.1.

2.2.
1

Tn y :..........................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. CMND
B. H chiu
S: ..........................................
Ngy cp:......../......../............ ti ....................... C quan cp............................
a ch:...................................................................................................................
S in thoi:................. S Fax:...............................E-mail:.............................
M s thu (nu c):...............................................................................................
T cch php l
A. Php nhn
B. C nhn hnh ngh ph thuc

A. Lin danh khng to php

AB. Khc

nhn
Nu r:..........................................
NI DUNG NGH
Nm ngh p dng Hip nh: .
i tng ngh khu tr thu np nc ngoi in cc thng tin c
ghi ti cc mc di y.
S thu ngh khu tr trc tip ........................................................................
- S thu nhp chu thu nc ngoi:....................................................................
- Loi thu nhp: .....................................................................................................
- Thi gian pht sinh thu nhp: ..............................................................................
- Thu sut: ...........................................................................................................
- S thu np nc ngoi: ..............................................................................
S thu khon ngh khu tr: ............................................................................

Trng hp i tng np thu u quyn cho i din hp php thc hin cc th tc p dng Hip nh, bn
c u quyn phi k khai y cc thng tin k c phn I.1. ca mu n ny.

2.3.

- S thu nhp nhn c nc ngoi thuc din khon thu: ...........................

- Loi thu nhp: .....................................................................................................
- Thi gian pht sinh thu nhp: .............................................................................
- Thu sut: ............................................................................................................
S thu ngh khu tr gin tip: ........................................................................
- S thu nhp chu thu nc ngoi: ...................................................................
- Loi thu nhp: .....................................................................................................
- Thi gian pht sinh thu nhp:...............................................................................
- Thu sut: ......................... ............................................................................
- S thu np nc ngoi: ..........................................................................

IV. THNG TIN V GIAO DCH PHT SINH THU NHP LIN QUAN
N S THU NGH P DNG HIP NH
1.
2.

Gii trnh tm tt v giao dch:

Ti liu gi km:
1.
2.
3...........

Ti cam kt cc thng tin v ti liu cung cp l trung thc v y v xin

chu trch nhim trc php lut v cc thng tin v ti liu ny.

NHN VIN I L THU

H v tn:.
Chng ch hnh ngh s:.......

Ngy .......thng ....nm ....

NGI NP THU hoc
I DIN HP PHP CA NGI NP THU
K, ghi r h tn, chc v v ng du

Mu s: 03/HTQT
(Ban hnh km theo Thng t
s 28/2011/TT-BTC ngy
28/2/2011 ca B Ti chnh)

GIY NGH XC NHN S THU NP TI VIT NAM

THEO HIP NH GIA VIT NAM V
.
(TN NC K KT)
(Dnh cho cc t chc, c nhn l i tng c tr nc ngoi)
ngh nh du (x) vo trng thch hp:
A.p dng cho t chc ;

I.

B. p dng cho c nhn; AB. p dng cho c c nhn v t chc

I TNG NGH

1. Ngi np thu:

A. T chc:

1.1.

1.2.
1.3.a

1.3.b.
1.4.
1.5.
1.6.
1.7.

1.8.

B. C nhn:

Tn y :...............................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. H chiu
S: ..........................................
Ngy cp:......../......../............ ti ....................... C quan cp.............................
Tn s dng trong giao dch
a ch ti Vit Nam........
S in thoi:S Fax: E-mail: ...
a ch trn l:
A.Vn phng D A. C s thng tr B.Ni lm vic B. Ni lu tr
AB. Khc Nu r: ..............
a ch giao dch ti Vit Nam (nu khc vi a ch nu trn)......
S in thoi:S Fax: E-mail:
M s thu ti Vit Nam (nu c): .............. ..........................................................
Thi gian c mt ti Vit Nam hoc thc hin hot ng ti Vit Nam:
a ch ti Nc k kt: ...............
S in thoi:S Fax: E-mail: ...
T cch php l
A. Php nhn
B. C nhn hnh ngh c lp

A. Lin danh khng to php

B. C nhn hnh ngh ph thuc

nhn
AB. Khc

Nu r......................................
M s thu ti Nc k kt (nu c)....................................................................

2. i din c u quyn2:
2.1.

2.2.
2.3.
2.4.

II.

Tn y :...............................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. CMND
B. H chiu
S: ..........................................
Ngy cp:......../......../............ ti ....................... C quan cp.............................
a ch:....................................................................................
S in thoi:................. S Fax:............................... E-mail:.............................
M s thu (nu c):..............................................................................................
T cch php l
A. Php nhn
B. C nhn hnh ngh ph thuc

A. Lin doanh khng to thnh

AB.
Khc

php nhn
AB. i l thu (nu c)
Nu r:........................................

I TNG CHI TR THU NHP

(Trng hp nhiu i tng chi tr thu nhp, phi lp bng k km theo Giy
ngh ny)
1.
Tn y :............................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. CMND
B. H chiu
S: ..........................................
Ngy cp:......../......../............ ti ....................... C quan cp...........................
2.
a ch:....................................................................................
S in thoi:................. S Fax:...............................E-mail:.............................
3.
M s thu (nu c):............................................................................................
4.
T cch php l
A. Php nhn
B. C nhn hnh ngh ph thuc

A. Lin danh khng to php

AB. Khc

nhn
Nu r:.........................................
III.
1.
2.

NI DUNG NGH
Nm ngh p dng Hip nh: ................................................
i tng ngh, tu theo mc ch xin p dng Hip nh, la chn v in
cc thng tin c ghi ti cc mc t mc a n b di y.

a.
a.1.
a.2.
a.3.
a.4.

Xc nhn s thu np ti Vit Nam:

S thu nhp chu thu ti Vit Nam: ....................................................................
Loi thu nhp:
Thi gian pht sinh thu nhp: ...............................................................................
S thu np: ......................................................................................................

Trng hp i tng np thu u quyn cho i din hp php thc hin cc th tc p dng Hip nh, bn
c u quyn phi k khai y cc thng tin k c phn I.1. ca mu n ny.

b.
Xc nhn s thu pht sinh ti Vit Nam nhng khng phi np do c
hng u i thu:

b.1.
b.2.
b.3.
b.4.

S thu nhp thuc din c u i: .....................................................................

Loi thu nhp:
Thi gian pht sinh thu nhp:...........................................................................
S thu/thu sut u i: ......................................................................................

IV. THNG TIN V GIAO DCH PHT SINH THU NHP LIN QUAN
N S THU NGH P DNG HIP NH
1.
2.

Gii trnh tm tt v giao dch:

Ti liu gi km:
1.
2.
3.

Ti cam kt cc thng tin v ti liu cung cp l trung thc v y v xin

chu trch nhim trc php lut v cc thng tin v ti liu ny.

NHN VIN I L THU

H v tn:.
Chng ch hnh ngh s:.......

Ngy .......thng ....nm ....

NGI NP THU hoc
I DIN HP PHP CA NGI NP THU
K, ghi r h tn, chc v v ng du

Mu s: 04/HTQT
(Ban hnh km theo Thng t
s 28/2011/TT-BTC ngy
28/2/2011 ca B Ti chnh)

TNG CC THU
General Department of Taxation
Cc Thu................................................................................
Tax Department of.......................
S (No.):

CNG HO X HI CH NGHA VIT NAM

Socialist Republic of Vietnam

c lp - T do - Hnh phc
Independence - Freedom - Happiness
----------------------------------..........................., ngy (day) .............thng (month) ............nm (year) ..............

GIY XC NHN THU THU NHP NP TI VIT NAM

Certificate of Income Tax Paid in Vietnam
(S dng cho thu thu nhp c nhn hoc thu nhp doanh nghip)
To be used for Personal Income Tax or Business Income Tax

I.

NGI NP THU:
TAXPAYER

nh du (x) vo trng thch hp: A.p dng cho t chc ; B. p dng cho c
nhn ; AB. p dng cho c c nhn v t chc.
Tick off (x) in the relevant box: A.for Entity ; B.for Individual ; AB. for Both

1.

2.
3.

4.

5.

6.

A. T chc:
B. C nhn:
Entity
Individual
Tn y
Full name.............................................................................................................
A. Giy php thnh lp
B. CMND
B. H chiu
Incorporation license
ID
Passport
S/Number:...............................................................
Ngy cp: .../.../ti ............................C quan cp
Issuing date:dd/mm/yy
in
Issuing authority
Tn s dng trong giao dch
Name used in transaction
T cch php l (Legal status)
A.Php nhn
B. C nhn hnh ngh ph thuc
Legal Entity
Individual carrying on dependent service
A. Lin danh khng to php nhn
B.C nhn hnh ngh c lp
Partnership not forming legal entity Individual carrying on independent service
AB. Khc
Nu r:............................................................
Other
Specify
i tng c tr ca nc
Resident of
AB. Vit Nam
AB. Nc k kt
AB. Nc khc..
Vietnam
Contracting State
Other
Giy php kinh doanh ti Vit Nam s (nu c ):
Number of business license in Vietnam (if any)
Ngy cp./../ti...C quan cp
Issuing date
in
issuing authority
M s thu ti Vit Nam (nu c)

7.

8.

Tax Indentification Number in Vietnam (if any)

a ch ti Vit Nam
Address in Vietnam
S in thoi/Tel:S Fax/Fax: E-mail:
a ch trn l:
This address is:
A. Tr s chnh
B.Ni lm vic
Headquarters
Office
A. Vn phng D
B. Ni lu tr
Representative Office
Domicile
A. C s thng tr
AB. Khc
Nu r:.......................
Permanent Establishment
Other
Specify
a ch ti nc lin quan (nc k kt hoc nc khc theo thng tin ti im I.4):
Address in relevant State (contracting state or other in conformity with information
in I.4 section).
S in thoi/Tel:S Fax/Fax: E-mail:
a ch trn l:
This address is:
A. Tr s chnh
B.Ni lm vic
Headquarters
Office
A. Vn phng D
B. Ni lu tr
Representative Office
Domicile
A. C s thng tr
AB. Khc
Nu r:.......................
Permanent Establishment
Other
Specify

II.

XC NHN S THU NP
Certifying tax paid
1. K tnh thu
Taxable period
t ngy..//..n.//.
From dd/mm/yy
to dd/mm/yy
2. Thu np
Tax paid
S thu phi np
Tax payable
Loi
S thu
S thu
S thu c
S thu
thu
thc
phi
nhp chu
S thu
min gim
phi np
nhp
np
thu
np*
Exempted or
Type
Total
of
tax
Taxable
Tax paid
reduced
Actual tax
of
payable
income
amount of tax
due
Income

Ngy
np
Due date

* Tng s thu np bng ch (Total tax paid in words) :

Cc thu tnh/thnh ph..........................................................xc nhn thu
(v/hoc min, gim) s thu thu nhp ca i tng np thu nu trn.
It
is
hereby
certified
that
the
TaxDepartment
of...............................................has received (and/or granted the exemption, the
reduction of) the mentioned income tax amount from (to) the above taxpayer.
Cc trng Cc thu.....................................................
Director of Tax Department of..................................................

K, ghi r h tn, v ng du (Sign, name and seal)

Mu s: 05/HTQT
(Ban hnh km theo Thng t
s 28/2011/TT-BTC ngy
28/2/2011 ca B Ti chnh)

TNG CC THU
General Department of Taxation
Cc Thu................................................................................
Tax Department of.......................
S (No.):

CNG HO X HI CH NGHA VIT NAM

Socialist Republic of Vietnam

c lp - T do - Hnh phc
Independence Freedom Happiness
----------------------------------..........................., ngy (day) .............thng (month) ............nm (year) ..............

GIY XC NHN THU THU NHP NP TI VIT NAM

I VI THU NHP T TIN LI C PHN, LI TIN CHO VAY,
TIN BN QUYN HOC PH DCH V K THUT
CERTIFICATE OF TAX PAID ON DIVIDEND, INTEREST, ROYALTY OR
TECHNICAL FEE
Cc thu tnh/thnh ph...........................................................................xc nhn
thu (v/hoc min, gim) s thu thu nhp ca i tng np thu di y i vi
thu nhp t:
The Tax Department of.........................................................certifies that it has
received (and/or granted the exemption, the reduction of) the income tax amount from
(to) the following taxpayer in respect of income on:
Tin li c phn Li tin cho vay Tin bn quyn Ph dch v k thut
Dividend
Interest
Royalty
Technical fee
i tng thc hng (beneficial owner)
Tn
(Name):.............................................................................................................................
a ch (kinh doanh hoc ni c tr):..............................................................................
Address (of business or resident place)
M s thu (hoc chng minh th/h chiu):...................................................................
Tax identification number (or I.D card/passport)
i tng c u quyn nhn thu nhp (trong trng hp khng phi l i tng
thc hng)
Designated person as beneficiary (other than the beneficial owner)
Tn (Name):.......................................................................................................................
a ch (kinh doanh hoc ni c tr):................................................................................
Address (of business or resident place)
M s thu (hoc chng minh th/h chiu):....................................................................
Tax identification number (or I.D card/passport)
i tng tr thu nhp (Income payer)
Tn (Name):.......................................................................................................................
a ch (kinh doanh hoc ni c tr):................................................................................

Address (of business or resident place)

M s thu (hoc chng minh th/h chiu):...............................................................
Tax identification number (or I.D card/passport)
L do chi tr thu nhp (reason for which the payment is made):
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
S thu phi np
Tax payable
Thu nhp
chu thu
Taxable
income

Tng s thu
phi np
Total of tax
payable

S thu thc
phi np
Actual tax
due

S thu c
min gim
Exempted or
reduced
amount of
tax

S thu
np*
Tax paid

Ngy np
Due date

* S thu np bng ch (Tax paid amount in words):...

.....
Cc trng Cc thu..........................................
Director of Tax Department of.............................
K, ghi r h tn, v ng du (Sign, name and seal)

Mu s: 06/HTQT
(Ban hnh km theo Thng t
s 28/2011/TT-BTC ngy
28/2/2011 ca B Ti chnh)

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
---------------&-----------------

H Ni, ngy..thng.nm 200..

Knh gi: ...............................................

GIY NGH XC NHN C TR CA VIT NAM

(Dnh cho cc t chc, c nhn l i tng c tr ca Vit Nam)

I.

Ngi np thu

nh du (x) vo trng thch hp: A.p dng cho t chc ; B. p dng cho c
nhn ; AB. p dng cho c c nhn v t chc
A. T chc
1.

2.
3.

4.a

4.b.
5.
6.
7.a

7.b.
8.

B. C nhn

Tn y :...........................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. CMND
B. H chiu
S:.........................................................................
Ngy cp: .../.../ti ...................................C quan cp........................
Tn s dng trong giao dch.
T cch php l
A. Php nhn
B. C nhn hnh ngh c lp
A.Lin danh khng to php nhn
B.C nhn hnh ngh ph thuc
AB. Khc Nu r:...........................................
a ch ti Vit Nam:
S in thoi:S Fax: E-mail:
a ch trn l:
A.Tr s chnh
B. Nh thng tr
AB. Khc Nu r...................
a ch giao dch ti Vit Nam (nu khc vi a ch nu trn).............................
S in thoi:S Fax: E-mail:
Quc tch: AB. Vit Nam AB. Nc k kt AB. Nc khc
M s thu ti Vit Nam (nu c): ............................ ...............................................
a ch ti Nc k kt:................................................................................................
S in thoi:S Fax: E-mail:
a ch trn l
A.Vn phng D A. C s thng tr B. Ni lm vic B. Ni lu tr
AB. Khc Nu r............................
a ch giao dch ti Nc k kt (nu khc vi a ch nu trn)...........................
S in thoi:S Fax: E-mail:
M s thu ti Nc k kt (nu c):....................................................................

Nm ngh xc nhn i tng c tr: t.n

Thi gian c mt ti Vit Nam trong cc nm xin xc nhn c tr (ch p dng i

vi c nhn)
1
2
3
Ngun thu nhp ch yu ca bn thn c nhn trong cc nm ni trn pht sinh t
(ch p dng i vi c nhn):
Vit Nam
Nc k kt
Nc khc ....................
II.

i din c u quyn3:

1.

Tn y :..........................................................................................................
A. Giy php kinh doanh hoc Giy php hnh ngh s...............................
B. CMND
B. H chiu
S:...........................................................................
Ngy cp: .../.../ti ...................................C quan cp........................
a ch giao dch:....................................................................................
S in thoi:................. S Fax:............................... E-mail:..............................
M s thu (nu c):.............................................................................................
T cch php l
A. Php nhn
B. C nhn hnh ngh ph thuc

A. Lin danh khng to php

AB. Khc

nhn
AB. i l thu (nu c)
Nu

r:...............................................

2.
3.
4.

Ti liu gi km:
1.
2.
3.
Ti cam kt cc thng tin v ti liu cung cp l trung thc v y v xin
chu trch nhim trc php lut v cc thng tin v ti liu ny.

NHN VIN I L THU

H v tn:.
Chng ch hnh ngh s:.......

Ngy .......thng ....nm ....

NGI NP THU hoc
I DIN HP PHP CA NGI NP THU
K, ghi r h tn, chc v v ng du

Trng hp ngi np thu u quyn cho i din hp php thc hin cc th tc p dng Hip nh, bn c
u quyn phi k khai y cc thng tin k c phn I ca mu Giy ngh ny.

Mu s: 07/HTQT
(Ban hnh km theo Thng t
s 28/2011/TT-BTC ngy
28/2/2011 ca B Ti chnh)

CNG HO X HI CH NGHA VIT NAM

TNG CC THU
GENERAL DEPARTMENT OF
TAXATION

CC THU...........
TAX DEPARTMENT OF

S/No.:

SOCIALIST REPUBLIC OF VIETNAM

c lp - T do - Hnh phc
Independence - Freedom - Happiness
----------------------------------

GIY CHNG NHN C TR

RESIDENCE CERTIFICATE
Tn i tng: ............................................................................................
Name:..............................................................................................................................................................................................................
M s ng k thu (nu c).............................................................................................................................................................................
Tax Identification Number (if any)............................................................................................................................................................
a ch: .............................................................................................................................................................................................................................................
Address: ..................................................................................................................................................................................................................................
Th theo Hip nh gia Chnh ph nc Cng ho X hi Ch ngha Vit Nam v
...................................................................................v trnh nh thu hai ln v ngn nga vic trn lu thu i
vi cc loi thu nh vo thu nhp, chng ti xc nhn rng i tng nu trn l i
tng c tr ca Vit Nam di gic thu theo lut ca nc Cng ho x hi ch
ngha Vit Nam v ph hp vi quy nh ti Hip nh ni trn trong thi gian
t.............................n.............................
In compliance with the Agreement between the Government of the Socialist Republic
of Vietnam and the Government of ......................................................................................................for the Avoidance of
Double Taxation and Prevention of Fiscal Evasion with respect to Taxes on Income, it
is hereby certified that the above-mentioned person is, by the laws of the Socialist
Republic of Vietnam and in accordance with this Agreement, a resident of Vietnam for
the taxation purposes for the period from.............................to.............................
Ngy.......................thng.......................nm.......................
Day.............month..........year
K tn (Signature)
Chc v ngi k (Designation)