Lampiran II

Peraturan Direktur Jenderal Pajak

Nomor: PER- 611PJ12009
Tanggal: 5 November 2009

MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA

DIRECTORATE GENERAL OF TAXES

CERTIFICATE OF DOMICILE OF NON RESIDENT

FOR INDONESIA TAX WITHHOLD ING (FO RM - DGT 1)
Gu ida nce :
Th is form is to be completed by a person (which includes a body of person, corpor ate or non corporate ):
who is a resident of a country which has concluded a Double Taxation Co nvention (DTC) with Indonesia; and
who claims relief from Indonesia Income Tax in respect of the following income earned in Indonesia (dividend, interest,
royalties, income from rendering services, and other income) subject to withho lding tax in Indonesia .
Do not us e thi s fo rm f or:
a banking institution, or
a person who claims relief from Indonesia Income Tax in respect of income arises from the transfer of bonds or stocks
which traded or registered in Indonesia stock exchange and ea rned the income or settled the transaction through a
Custod ian in Indonesia, other than interest and dividend ,
All particulars in the form are to be properly furnished, and the form shall be signed as comp leted. This form must be certified
by the Competent Author ity or his authorized representative or authorized tax office in the country wh ere the income recipient
is a taxpayer resident before submitted to Indonesia withholding agent.

NAME OF THE COUNTRY OF INCOME RECIPIENT

(] ]

INDONESIA WITHHOLDING AGENT:

INCOME RECIPIENT :
Tax 10 Nu mber

_ _ _ _ _ _ _ _ _ _ _ _ _ (2) Tax 10 Nu mber

Na me

_ _ _ _ _ _ _ _ _ _ _ _ (3 )

Na me

_ _ _ _ _ _ _ _ _ _ (6 ]

Add ress

_ _ _ _ _ _ _ _ _ _ _ _ (4 )

Add ress

_ _ _ _ _ _ _ _ _ _ (7 ]

_ _ _ _ _ _ _ _ _ (5]

DECLARATION BY THE INCOME RECIPIENT :

I, (full name )
(R) hereby de clare that I have e xamine d the
inf orm at io n pro vided in this fo rm a nd to the best of my knowledge and be lief il is tr ue, co rrect , a nd co mplete . I furt her
de cla re that 0 I a m c thi s co m pa ny is not a n Indon e sia re sident taxpayer. (Please check the box aCCOfdingly)

0::==========19]
Signature of the income recipient or individual
authorized to sign for the income recipient

---.!_

'_

= = =,(12)
-==
= = ==(11) - 0:=
Capacity in which acting
contact Number

( IO)

Date (mmiddlyy)

CERTIFI CATION BY COMPETENT AUTHORIT Y OR AUTHORIZED TAX OFFI CE OF THE

COUNT RY OF RESIDEN CE :
Fo r the purpose of tax re lief, it is hereby co nfirmed that the taxpaye r mention ed in Part I is a res ident in
-,,,,,,,--;:= o-:== - ,oc.,--,( 13){name of/ha stal al w ithin the mea ning of the Doub le Taxation Co nve ntion in accorda nc e
w ith Do ub le Taxation Co nvention concluded between Indon es ia and
(14) {nama of the state of
resid ance! .

Date (mm/dd/yyyy): _ 1_' _ _( 17)

= ===========",(15)

Name and Signature of the Competent Authority or his

authorized representative or authorized tax office

OffiCial
Stamp
(if any)

Offi ce ad dress:
_ _ _ _ _ _ _ _ _ _ _ _ _(18)

_-,==
= = = = = .,--,(16)
Capacity/designation 01signatory

This form is available and rna be dow nloaded a/ this website: hll Jlwww . alak.o.ld
This cartlflcate is valid for 12 (Iwelve) months comm ancing from Ihe dale of cartilicafi'o n,

Pa g e 1

Part IV

TO BE COMPLETED IF THE INCOME RECIPIENT IS AN INDIVIDUAL

1.

Name of Income Recipient :

2.

Date of birth (mm/dd/yyyy) : _ 1_1__ (20)

( 19)

I 3 . Are you acting as an agent or a nominee?

Yes 0 No ')

::J

4. Full address:

(21)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _: 5.

Do you have permanent home in Indonesia?

6.

In what country do you ordinarily reside?

7. Have you ever been resided in Indonesia?

Yes

-'(22)

No ') (23)

(24)
::J

Yes

No')

::J

If so, in what period? _ f _I__ to _ 1-1__(25 )

Please provide the address

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

Yes

No '

(26)

If so, please provide the address

Part V

TO BE COMPLETED IF THE INCOME RECIPIENT IS NON INDIVIDUAL

1.

Country of registrationlincorporation: - - - - - - - - - - - - - - - - - - - - -

(27)

2.

Wh ich country does the place of management or control reside?

'( 28)

3.

Address of Head Office:

(29)

4.

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

(30)

5.

Nature of business (i.e. Pension Fund, Insurance, Headquarters, Financ ing)

(31 )

6.

The company is listed in stock market and the shares are regularly traded .
If yes, please provide the name of the stock market:

e Yes c No ' j
(32)

7.

The creation of the entity and/or the transaction structure is not motivated by reasons to take
advantage of benefit of the DTC,
(33 )

Yes

8.

The company has its own management to conduct the business and such management has an
independent discretion.
(34)

D Yes n No')

9.

The company employs sufficient qualified personnel.

(35)

e Yes c No')

10. The company engages in active conduct of a trade or business.

( 36 )

D Yes n No')

11. The earned income is subject to tax in your country.

(37)

e Yes c No')

12. No more than 50 per cent of the company's income is used to satisfy claims by other persons
(l.e . interest, royalties, other fees)
(38)

e Yes c No')

No')

INCOME EARNED FROM INDONESIA IN RESPECT TO WHICH RELIEF IS CLAIMED

1. Div idend , Interest, o r Royalti es :
a . Type of Income:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(39)

b. Amount of Income liable to withholding tax under Indonesian law:

lOR

(40 )

2. Income fr om renderin g serv ices (incl uding profess ional ):

a . Type of incomes:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (4 1)

b. Amount of Income liable to withholding tax under Indonesian law:

c. Period of engagement (mm/dd/yy): ( H )
.... From: _ I_ I_ _ to _ 1_1_ _

.... From: _

... From:

.... From:

lI

to

I_

lOR

I_ _ to _
1

to

_ _ _ _ _ _ _ _ _ _ (42)

1_1_ _
I

3. Ot her Type of Income:

a . Type of incomes:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (44)

b. Amount of Income liable to withholding tax under Indonesian law:

lOR

(45)

This form is available and may be downloaded a/this website: hltp/lwww.paiak.ao .id
OJ Please check the appropriate

oox

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.

Signature of the income recipient or individual

authorized to sign for the income recipient

1_1 -

Date (mmiddiyy)

Page 2

Capacity in which acting

Con tactNumber

INSTRU CTIO NS
FOR CERTIFICATE OF DOMICILE OF NON RESIDENT
FOR INDONESIA TAX WITHHOLD ING (FORM - DGT 1)

Numbe r 1:
Please fill In the name of the oountry of income recipient.
Part I

Inform ati on of Inco me Recip ie nt:

Numbe r 2 :
Please flil in the inoome reopre nrs taxpayer ldentrncauc n
number In country where the clarmant is registered as a resident
taxpayer.
Numbe r 3:
Please fill In the Income recoe nrs name .
Numbe r 4 :
Please fill In the Income recoe nrs address .
Numbe r S:
Please fill in the Indonesia w,thholding agenfs taxpayer
ldennncauon number.
Numbe r 6 :
Please fill In the Indonesia withholding agent's name.
Numbe r 7:
Please fill In the Indonesia withholding agent's address.
Part II

Dec la ratio n by the Inco me Recip ient :

Number 8:
In case the income recioent is not an individual this form shall
be f,lled by the management of the income reclprent. Please fill
in the name of person authonzed to sign on behalf the inoome
recfprer rt. If the income recipient is an Ind,v,dual, please fill in the
name as stated in Number 3.
Number 9:
The income reopren t or his represe ntative (for non indiv,dual)
shall s,gn tt us form.
Numbe r 10:
Please fill In the place and date of signing
Numbe r 11:
Please fill In the ca pacity of the ctaen ant or his representative
who signs tt ns form.
Number 12:
Please fill In the contact number of person who signs this form.
Part III Cert if ication by Com petent Aut hority or Auth o rize d
Tax Office of t he Co untry of Res idence:
Numbe r 13 and 14 :
Please f,11in the name of co untry where the Income recipient IS
registered as a resident taxpayer.
Numbe r 1S and 16
The Co mpetent Authontres or his authonzed representanva or
authonzed tax office should certify this form by s,gnlng It. The
posmon of the signor should be filled in Number 16
Numbe r 17:
Please fill In the date when the form is sog ned by the Competent
Aumonne s or h,s authorized representative or authonzed tax
office.
Numbe r 18:
Please fill in the office address of the Co mpetent Authonty or
authonzed representative or authorized tax office
Part IV to be co mp let ed If t he Inc ome Rec ipient is an
Indiv idual:
Numbe r 19:
Please fill In the Income recoe nrs full name
Numbe r 20:
Please fill In the Income recipien t's date of birth.
Numbe r 2 1:
Please check the appropnete box You are acting as an agent if
yo u act as an Intermediary or act for and on behalf of other party

In relation wrth the income source In lndonasra. You are acting

as a nominee If you are the legal ow ner of income or of asse ts
that the inoome is generated and yo u are not the real owner of
the income or assets
Numbe r 22 :
Please fill In the Income recipien t's address .
Numbe r 23:
Please check the appropriate box If your perma nent home IS In
tnoones.a, you are co nsidered as lndcn esran reserent taxpayer
according to the Inoome Tax l aw and if you receive inoome from
tnoones.a, the Do uble Tax Conventions shall not be applied
Numbe r 24 :
Please fill the name of co untry where yo u oromanly res.oe
Number 25:
Please check the appropnate box. In case yo u have ever been
resided in Indonesia, please f,11 the pence of your stay and
address where you are resided.
Numbe r 26 :
Please check the appropriate box. In case you have any otrces ,
or other place of busoess in lndonasra, please fill In the address
of the cruces. or other place of busin ess In tnoc oese
Part V To be Co mp leted if t he Inc ome Rec ip ie nt is non
Indiv idual:
Numbe r 21 :
Please fill in the country where the entoty IS registered or
Incorporated .
Numbe r 28:
Please f,11in the oountry where the entity IS co ntrolled or where
its management is seueteo.
Numbe r 29 :
Please fill In the address of the entoty's Head Office.
Number 30:
Please fill In the address of any branches, offic es, or other place
of business of the entity situ ated In tnoc nes.a.
Numbe r 31:
Please fill In the nature of busmass of the claimant.
Number 32-38 :
Please check the appropriate box In acco rdance wrth the
ctaunant's facts and CI rcumstances.
Part VI for Inco me Earned f rom Indonesia in Respect to
w hic h relief is c laimed :
Numbe r 39:
Please fill In the type of Income (e g. d,vidend, Interest, or
royalties).
Numbe r 40:
Please fill in the aggregate amount of Income liable to
w,thholdlng tax under moc nes.an l aw WIthin a period of month
(Tax Penod ).
Number4 1:
Please fill In the type of income from rendering services
(includ,ng professional).
Numbe r 42 :
Please f,11 in the aggregate amount of Income liable to
w,thholdlng tax under tnoc nes.en l aw WIthin a period of month
(Tax Penod ).

Number 43:
In case your income rs arising from rendenng service. please fill
in the penod when the service rs provided

Numbe r 44:
Please flll ,n the other type of income
Numbe r 45:
Please f,ll in the amount of Inoome liable 10 wrthholdmq tax
under Indonesian l aw,