Недействующий

О формах к инструкции Госналогслужбы России от 16.06.95 N 34 (фактически не применяется)

┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰                  Поля заполняются печатными буквами
│   │ │   │ │ Х │ │ Х │ │ Х │ │ Х │ │ Х │ │ Х │                  Fields are filled by block letters
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   Заявителю For the Claimant ____________________________________________________

   Соглашение об избежании двойного налогообложения между Российской Федерацией и
   Double Taxation Convention between the Russian Federation and ____________________________

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1011DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на возврат налога с дохода от источников            │         За for           │
│ Form 1011DT (1997)                  │                    в Российской Федерации                      │            ┌———‰         │
│ the State Tax Service of Russia     │                 (кроме дивидендов/процентов)                   │         199│   │         │
│                                     │            for a refund of tax withheld in Russia on           │            └———…         │
│                                     │               income (except dividends/interest)               │                          │
│                                     │                                                                │                          │
├┬———————————————————————┬————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
││                       │                                                                                                        │
││Место штампа "ПОЛУЧЕНО"│                      Отметка Госналогинспекции о получении Уведомления                                 │
│└———————————————————————…                                                                                                        │
│                                                                                                                                 │
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │ 

│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН в стране регистрации                              ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰     │
│Identification tax number in country of registration  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…     │
│                                                                                                                                 │
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│3. Сведения об источнике дохода                                                                                                  │
│   Information about source of income                                                                        Номер**   ┌———┬———‰ │
│                   ┌———————————————————————————————————————————————————————‰                                           │   │   │ │
│Вид дохода         │                                                       │                                 Number**  └———┴———… │
│Type of income     └———————————————————————————————————————————————————————…                                                     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Контрагент                                 Наименование        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│Contractor                                                     └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                               ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│                                           Name in full        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                                                                                                 │
│                                                               ┌——————————————————————————————————————————————————————————————‰  │
│                                           Полный адрес        │                                                              │  │
│                                           Full address        └——————————————————————————————————————————————————————————————…  │
│                                                                                                                                 │
│                                                                                                                                 │
│                                           ИНН                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰      │
│                                           Identification tax number   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Договор                                    Номер    ┌————————————————————————————————‰          Дата                             │
│Contract                                            │                                │                  ┌——┬——┬——┬——┬——┬——‰      │
│                                           Number   └————————————————————————————————…          Date    └——┴——┴——┴——┴——┴——…      │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————┬———————————————————————————————————————————┤
│Общая сумма дохода                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰     │          Код валюты*                      │
│до удержания налога                        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…     │          Currency code*                   │
│в целых единицах                                                                     │                                           │
│Cross amount of income                     Дата начисления                           │                                           │
│in whole currency units                    дохода            ┌——┬——┬——┬——┬——┬——‰     │              ┌——┬——┬——‰                   │
│                                           Date of accrued   └——┴——┴——┴——┴——┴——…     │              └——┴——┴——…                   │
│                                           of income                                 │                                           │
├—————————————————————————————————————————————————————————————————————————————————————┤                                           │
│Сумма удержанного налога                   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰     │                                           │
│Tax withheld                               └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…     │                                           │
├—————————————————————————————————————————————————————————————————————————————————————┴———————————————————————————————————————————┤
│Сумма налога, подлежащая                                                                        Ставка налога                    │
│удержанию по Соглашению                                                                         Tax Rate            ┌——┬——‰      │ 

│Tax under the Treaty                       ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                    └——┴——…      │
│                                           └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                                 │
├—————————————————————————————————————————————————┬———————————————————————————————————————————————————————————————————————————————…
│Общая сумма налога, подлежащая возврату          │      ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰
│Total amount to be reimbursed                    │      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…
└—————————————————————————————————————————————————…


     Приложение на ________ страницах  Enclosures on ________ pages
————————————————

* По справочнику "BIC directory". By reference book "BIC directory".  

** Порядковый номер по Перечню видов доходов, приведенному на экземпляре формы, остающейся у Заявителя. Order number in the List of the types of income, named in the Claimant's copy of the Form.



┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰
│   │ │   │ │ Х │ │   │ │   │ │   │ │ Х │ │ Х │
└———… └———… └———… └———… └———… └———… └———… └———…

Форма Form 1011DT (1997)                                              Стр. Page 2
——————————————————————————————————————————————————————————————————————————————————————————————————
┌—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│4. Банк получателя платежа                Bank of recipient                                                                      │
│                                                                                                                                 │
│                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                │
│           Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                │
│                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                │
│           Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│                        ┌——————————————————————————————————————————————————————————————————————————————————————————————————————‰ │
│           Полный адрес │                                                                                                      │ │
│                        └——————————————————————————————————————————————————————————————————————————————————————————————————————… │
│                                                                                                                                 │
│                                                                                                                                 │
│                                                    Cтрана  ┌———————————————————————————‰             Код           ┌———┬———‰    │
│                                                            │                           │                           │   │   │    │
│Full residential address                                    │                           │                           └———┴———…    │
│                                                    Country └———————————————————————————…             Country code               │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤

│                                                                                                                                 │
│           Номер счета                    ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰              │
│           Number of Bank account         └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…              │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Заявляю, что:                                                                                                                    │
│                                                                                                                                 │
│I declare that                                                                                                                   │
│                                                                                                                                 │
│  указанные доходы не связаны с деятельностью на территории Российской Федерации;                                                │
│                                                                                                                                 │
│  the above mentioned income is not  connected with activities carried in the Russian Federation                                 │
│                                                                                                                                 │
│  на дату начисления, указанную в разделе 3 Заявления, имелось фактическое право на получение                                    │
│  этих доходов                                                                                                                   │
│                                                                                                                                 │
│  on the date of accrued entered in paragraph 3, above, recipient of the above income has being                                  │
│  the beneficial owner                                                                                                           │
│                                                                                                                                 │
│Настоящим подтверждаю достоверность указанных сведений.                                                                          │
│                                                                                                                                 │
│I hereby confirm that the information provided herewith is accurate                                                              │
│                                                                                                                                 │
│┌————————————————————‰                                   ┌——————————————————————————————————————————‰  Должность                 │
││                    │                                   │                                          │  Occupation                │
││                    │                                   └——————————————————————————————————————————…                            │
││                    │ Печать                            ┌——————————————————————————————————————————‰  Имя                       │
││                    │ Stamp                             │                                          │  Name                      │
││                    │                                   └——————————————————————————————————————————…                            │
││                    │                                   ┌——————————————————————————————————————————‰  Подпись                   │
││                    │                                   │                                          │  Signature                 │
│└————————————————————…                                   └——————————————————————————————————————————…                            │
│                                                                                                                                 │
│                                                                                                                                 │
│                                                  ┌——┬——┬——┬——┬——┬——‰ Дата                                                       │
│                                                  └——┴——┴——┴——┴——┴——… Date                                                       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│5. Заполняется уполномоченным налоговым органом иностранного государства                                                         │
│   Note of the foreign Tax authority                                                                                             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Подтверждается, что заявитель действительно являлся в течение _______ лицом с постоянным                                         │
│местопребыванием в                                                                                                               │
│                                                                                                                                 │
│It is hereby confirmed that the claimant during__________________________________________________________________________       │
│was a resident of________________________________________________________________________________________________________       │
│                             название страны/name of the country                                                                 │
│                                                                                                                                 │
│в смысле Соглашения об избежании двойного налогообложения между СССР/Российской Федерацией и                                     │
│in the sense implied in the Double Taxation Convention between the USSR/Russian Federation and                                   │
│__________________________________________________________________________________________________________________________       │
│                              название страны/name of the country                                                                │
│                                                                                                                                 │
│                                         ┌——————‰                                                                                │
│Заявленные доходы подлежат               │      │ налогообложению в стране постоянного                                           │
│The claimed incomes are taxable          └——————… местопребывания                             (отметить     )                    │
│                                         ┌——————‰                                                     ┌———‰                      │
│┌————————————————————‰  не подлежат      │      │ in the country                              (mark   │ Х │ )                    │
││                    │  not taxable      └——————… of residence                                        └———…                      │
││                    │                                                                                                           │
││                    │  Печать      ┌——————————————————————————————————————————‰ Дата и место заполнения                         │ 

││                    │  Stamp       │                                          │       Date and Place                            │
││                    │              └——————————————————————————————————————————…                                                 │
││                    │              ┌——————————————————————————————————————————‰          Подпись                                │
││                    │              │                                          │          Signature                              │
│└————————————————————…              └——————————————————————————————————————————…                                                 │
└—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————…
┌————————————————————————————————————————————————————‰
│   Перечень видов доходов  List of types of income  │
├————┬————————————————————————┬——————————————————————├————┬————————————————————————┬——————————————————————‰
│ N  │ Наименование           │Type                  │    │ Наименование           │Type                  │
└————┴————————————————————————┴——————————————————————┴————┴————————————————————————┴——————————————————————…
┌————┬————————————————————————┬——————————————————————┬————┬————————————————————————┬——————————————————————‰
│    │                        │                      │    │                        │                      │
│ 01 │Дивиденды               │Dividends             │ 10 │Процентный доход        │Interest from         │
│    │                        │                      │    │                        │                      │
│ 02 │Доходы                  │Income from           │    │по другим ценным        │other paper           │
│    │                        │                      │    │                        │                      │
│    │от долевого             │underwriting shares   │    │бумагам                 │                      │
│    │                        │                      │    │                        │                      │
│    │участия                 │                      │ 11 │Процентный доход        │Interest from         │
│    │                        │                      │    │                        │                      │
│ 03 │Доходы от               │Income from           │    │от штрафов и пени       │penalties             │
│    │                        │                      │    │                        │                      │
│    │инвестиционных          │investment            │ 12 │Лицензионные            │Royalties             │
│    │                        │                      │    │                        │                      │
│    │фондов и т.п.           │funds etc.            │    │платежи (роялти)        │                      │
│    │                        │                      │    │                        │                      │
│    │                        │                      │    │                        │                      │
│ 04 │Процентный              │Interest from         │ 13 │Доходы от аренды        │Income from           │
│    │                        │                      │    │                        │                      │
│    │доход по                │corresponding         │    │(лизинга)               │leasings of           │
│    │                        │                      │    │                        │                      │
│    │корреспондентским       │accounts              │    │движимого               │movable               │
│    │                        │                      │    │                        │                      │
│    │счетам                  │                      │    │имущества               │property              │
│    │                        │                      │    │                        │                      │
│ 05 │Процентный              │Interest from         │ 14 │Доходы от аренды        │Income from           │ 

│    │                        │                      │    │                        │                      │
│    │доход по кредитам       │credits               │    │(лизинга)               │leasings of           │
│    │                        │                      │    │                        │                      │
│ 06 │Процентный              │Interest from         │    │недвижимого             │real estate           │
│    │                        │                      │    │                        │                      │
│    │доход по                │deposits              │    │имущества               │                      │
│    │                        │                      │    │                        │                      │
│    │депозитам               │                      │ 15 │Премии по прямому       │Premiums from         │
│    │                        │                      │    │                        │                      │
│ 07 │Процентный              │Interest from         │    │страхованию и           │direct                │
│    │                        │                      │    │                        │                      │
│    │доход по                │corporate bonds       │    │сострахованию           │insurance and         │
│    │                        │                      │    │                        │                      │
│    │корпоративным           │                      │    │                        │coinsurance           │
│    │                        │                      │    │                        │                      │
│    │облигациям              │                      │ 16 │Премии по               │Premiums from         │
│    │                        │                      │    │                        │                      │
│ 08 │Процентный              │Interest from state   │    │перестрахованию         │reinsurance           │
│    │                        │                      │    │                        │                      │
│    │доход по                │bonds                 │ 17 │Проценты на депо        │Interest on           │
│    │                        │                      │    │                        │                      │
│    │государственным         │                      │    │премий                  │depo of               │
│    │                        │                      │    │                        │                      │
│    │облигациям              │                      │    │                        │premiums              │
│    │                        │                      │    │                        │                      │
│ 09 │Процентный              │Interest (discount)   │ 18 │Другие доходы           │Other income          │
│    │                        │                      │    │                        │                      │
│    │(дисконтный)            │from notes            │    │                        │                      │
│    │                        │                      │    │                        │                      │
│    │доход по векселям       │                      │    │                        │                      │
└————┴————————————————————————┴——————————————————————┴————┴————————————————————————┴——————————————————————…


                                                              ┌———————————————————————————————————————————‰
┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰               │  Поля заполняются печатными буквами       │
│   │ │   │ │ Х │ │   │ │   │ │ Х │ │ Х │ │ Х │               │  Fields are filled by block letters       │
└———… └———… └———… └———… └———… └———… └———… └———…               └———————————————————————————————————————————…



   В уполномоченный налоговый орган Заявителя
   For Claimant's foreign Tax authority __________________________________________


   Соглашение об избежании двойного налогообложения между Российской Федерацией и

   Double Taxation Convention between the Russian Federation and _________________

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1011DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на возврат налога с дохода от источников            │         За for           │
│ Form 1011DT (1997)                  │                    в Российской Федерации                      │            ┌———‰         │
│ the State Tax Service of Russia     │                 (кроме дивидендов/процентов)                   │         199│   │         │
│                                     │            for a refund of tax withheld in Russia on           │            └———…         │
│                                     │               income (except dividends/interest)               │                          │
│                                     │                                                                │                          │
├┬———————————————————————┬————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
││                       │                                                                                                        │
││Место штампа "ПОЛУЧЕНО"│                      Отметка Госналогинспекции о получении Уведомления                                 │
│└———————————————————————…                                                                                                        │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │ 

├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН в стране регистрации                              ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰     │
│Identification tax number in country of registration  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│3. Сведения об источнике дохода                                                                                                  │
│   Information about source of income                                                                        Номер**   ┌———┬———‰ │
│                   ┌———————————————————————————————————————————————————————‰                                           │   │   │ │
│Вид дохода         │                                                       │                                 Number**  └———┴———… │
│Type of income     └———————————————————————————————————————————————————————…                                                     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Контрагент                                 Наименование        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│Contractor                                                     └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                               ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│                                           Name in full        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                                                                                                 │
│                                                               ┌——————————————————————————————————————————————————————————————‰  │
│                                           Полный адрес        │                                                              │  │
│                                           Full address        └——————————————————————————————————————————————————————————————…  │
│                                                                                                         

                       │
│                                                                                                                                 │
│                                           ИНН                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰      │
│                                           Identification tax number   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Договор                                    Номер    ┌————————————————————————————————‰          Дата                             │
│Contract                                            │                                │                  ┌——┬——┬——┬——┬——┬——‰      │
│                                           Number   └————————————————————————————————…          Date    └——┴——┴——┴——┴——┴——…      │
│                                                                                                                                 │
├————————————————————————————————————————————————————————————————————————————————————————————————————┬————————————————————————————┤
│Общая сумма дохода                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │   Код валюты*              │
│до удержания налога                        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                    │   Currency code*           │
│в целых единицах                                                                                    │                            │
│Cross amount of income                     Дата начисления дохода                                   │                            │
│in whole currency units                                                 ┌——┬——┬——┬——┬——┬——‰         │     ┌——┬——┬——‰             │
│                                           Date of accrued of income    └——┴——┴——┴——┴——┴——…         │     └——┴——┴——…             │
│                                                                                                    │                            │
├————————————————————————————————————————————————————————————————————————————————————————————————————┤                            │
│Сумма удержанного налога                   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │                            │
│Tax withheld                               └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                    │                            │
├————————————————————————————————————————————————————————————————————————————————————————————————————┴————————————————————————————┤
│Сумма налога, подлежащая                                                                             Ставка налога               │
│удержанию по Соглашению                                                                              Tax Rate       ┌——┬——‰      │
│Tax under the Treaty                       ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                    └——┴——…      │
│                                           └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                                 │
├—————————————————————————————————————————————————┬———————————————————————————————————————————————————————————————————————————————…
│Общая сумма налога, подлежащая возврату          │      ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰
│Total amount to be reimbursed                    │      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…
└—————————————————————————————————————————————————…


     Приложение на ________ страницах  Enclosures on ________ pages
————————————————

* По справочнику "BIC directory". By reference book "BIC directory".

** Порядковый номер по Перечню видов доходов, приведенному на экземпляре формы, остающейся у Заявителя. Order number in the List of the types of income, named in the Claimant's copy of the Form.



┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰

│   │ │   │ │ Х │ │   │ │   │ │   │ │ Х │ │   │
└———… └———… └———… └———… └———… └———… └———… └———…

Форма Form 1011DT (1997)                                              Стр. Page 2
——————————————————————————————————————————————————————————————————————————————————————————————————
┌—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│4. Банк получателя платежа                Bank of recipient                                                                      │
│                                                                                                                                 │
│                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                │
│           Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                │
│                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                │
│           Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│                        ┌——————————————————————————————————————————————————————————————————————————————————————————————————————‰ │
│           Полный адрес │                                                                                                      │ │
│                        └——————————————————————————————————————————————————————————————————————————————————————————————————————… │
│                                                                                                                                 │
│                                                                                                                                 │
│                                                    Cтрана  ┌———————————————————————————‰             Код           ┌———┬———‰    │
│                                                            │                           │                           │   │   │    │
│Full residential address                                    │                           │                           └———┴———…    │
│                                                    Country └———————————————————————————…             Country code               │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│           Номер счета                    ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰              │
│           Number of Bank account         └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…              │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Заявляю, что:                                                                                                                    │
│                                                                                                                                 │
│I declare that                                                                                                                   │
│                                                                                                                                 │ 

│  указанные доходы не связаны с деятельностью на территории Российской Федерации;                                                │
│                                                                                                                                 │
│  the above mentioned income is not  connected with activities carried in the Russian Federation                                 │
│                                                                                                                                 │
│  на дату начисления, указанную в разделе 3 Заявления, имелось фактическое право на получение                                    │
│  этих доходов                                                                                                                   │
│                                                                                                                                 │
│  on the date of accrued entered in paragraph 3, above, recipient of the above income has being                                  │
│  the beneficial owner                                                                                                           │
│                                                                                                                                 │
│Настоящим подтверждаю достоверность указанных сведений.                                                                          │
│                                                                                                                                 │
│I hereby confirm that the information provided herewith is accurate                                                              │
│                                                                                                                                 │
│┌————————————————————‰                                   ┌——————————————————————————————————————————‰  Должность                 │
││                    │                                   │                                          │  Occupation                │
││                    │                                   └——————————————————————————————————————————…                            │
││                    │ Печать                            ┌——————————————————————————————————————————‰  Имя                       │
││                    │ Stamp                             │                                          │  Name                      │
││                    │                                   └——————————————————————————————————————————…                            │
││                    │                                   ┌——————————————————————————————————————————‰  Подпись                   │
││                    │                                   │                                          │  Signature                 │
│└————————————————————…                                   └——————————————————————————————————————————…                            │
│                                                                                                                                 │
│                                                                                                                                 │
│                                                  ┌——┬——┬——┬——┬——┬——‰ Дата                                                       │
│                                                  └——┴——┴——┴——┴——┴——… Date                                                       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│5. Заполняется уполномоченным налоговым органом иностранного государства                                                         │
│   Note of the foreign Tax authority                                                                                             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Подтверждается, что заявитель действительно являлся в течение _______ лицом с постоянным                                         │
│местопребыванием в                                                                                                               │
│                                                                                                                                 │
│It is hereby confirmed that the claimant during__________________________________________________________________________       │
│was a resident of________________________________________________________________________________________________________       │
│                             название страны/name of the country                                                                 │
│                                                                                                                                 │
│в смысле Соглашения об избежании двойного налогообложения между СССР/Российской Федерацией и                                     │
│in the sense implied in the Double Taxation Convention between the USSR/Russian Federation and                                   │
│__________________________________________________________________________________________________________________________       │
│                              название страны/name of the country                                                                │
│                                                                                                                                 │
│                                         ┌——————‰                                                                                │
│Заявленные доходы подлежат               │      │ налогообложению в стране постоянного                                           │
│The claimed incomes are taxable          └——————… местопребывания                             (отметить     )                    │
│                                         ┌——————‰                                                     ┌———‰                      │
│┌————————————————————‰  не подлежат      │      │ in the country                              (mark   │ Х │ )                    │
││                    │  not taxable      └——————… of residence                                        └———…                      │
││                    │                                                                                                           │
││                    │  Печать      ┌——————————————————————————————————————————‰ Дата и место заполнения                         │
││                    │  Stamp       │                                          │       Date and Place                            │
││                    │              └——————————————————————————————————————————…                                                 │
││                    │              ┌——————————————————————————————————————————‰          Подпись                                │
││                    │              │                                          │          Signature                              │
│└————————————————————…              └——————————————————————————————————————————…                                                 │
└—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————…




┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰                  Поля заполняются печатными буквами
│   │ │   │ │ Х │ │   │ │   │ │ Х │ │ Х │ │   │                  Fields are filled by block letters
└———… └———… └———… └———… └———… └———… └———… └———…




   В Госналогинспекцию по                                       ┌——┬——┬——┬——‰
   To the State Tax Office __________________________________ N └——┴——┴——┴——…


   Соглашение об избежании двойного налогообложения между Российской Федерацией и
   Double Taxation Convention between the Russian Federation and ________________

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1011DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на возврат налога с дохода от источников            │         За for           │
│ Form 1011DT (1997)                  │                    в Российской Федерации                      │            ┌———‰         │
│ the State Tax Service of Russia     │                 (кроме дивидендов/процентов)                   │         199│   │         │
│                                     │            for a refund of tax withheld in Russia on           │            └———…         │
│                                     │               income (except dividends/interest)               │                          │
│                                     │                                                                │                          │
├┬———————————————————————┬————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
││                       │                                                                                                        │
││Место штампа "ПОЛУЧЕНО"│                      Отметка Госналогинспекции о получении Уведомления                                 │
│└———————————————————————…                                                                                                        │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │ 

│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН в стране регистрации                              ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰     │
│Identification tax number in country of registration  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│3. Сведения об источнике дохода                                                                                                  │
│   Information about source of income                                                                        Номер**   ┌———┬———‰ │
│                   ┌———————————————————————————————————————————————————————‰                                           │   │   │ │
│Вид дохода         │                                                       │                                 Number**  └———┴———… │
│Type of income     └———————————————————————————————————————————————————————…                                                     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Контрагент                                 Наименование        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│Contractor                                                     └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                               ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│                                           Name in full        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                                                                                                 │
│                                                               ┌——————————————————————————————————————————————————————————————‰  │
│                                           Полный адрес        │                                                              │  │
│                                           Full address        └——————————————————————————————————————————————————————————————…  │
│                                                                                                                                 │
│                                                                                                                                 │
│                                           ИНН                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰      │
│                                           Identification tax number   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Договор                                    Номер    ┌————————————————————————————————‰          Дата                             │
│Contract                                            │                                │                  ┌——┬——┬——┬——┬——┬——‰      │
│                                           Number   └————————————————————————————————…          Date    └——┴——┴——┴——┴——┴——…      │
│                                                                                                                                 │
├————————————————————————————————————————————————————————————————————————————————————————————————————┬————————————————————————————┤
│Общая сумма дохода                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │   Код валюты*              │
│до удержания налога                        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                    │   Currency code*           │
│в целых единицах                                                                                    │                            │
│Cross amount of income                     Дата начисления дохода                                   │                            │
│in whole currency units                                                 ┌——┬——┬——┬——┬——┬——‰         │     ┌——┬——┬——‰             │
│                                           Date of accrued of income    └——┴——┴——┴——┴——┴——…         │     └——┴——┴——…             │
│                                                                                                    │                            │
├————————————————————————————————————————————————————————————————————————————————————————————————————┤                            │
│Сумма удержанного налога                   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │                            │
│Tax withheld                               └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                    │                            │
├————————————————————————————————————————————————————————————————————————————————————————————————————┴————————————————————————————┤
│Сумма налога, подлежащая                                                                             Ставка налога               │
│удержанию по Соглашению                                                                              Tax Rate       ┌——┬——‰      │
│Tax under the Treaty                       ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                    └——┴——…      │
│                                           └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                                 │
├—————————————————————————————————————————————————┬———————————————————————————————————————————————————————————————————————————————…
│Общая сумма налога, подлежащая возврату          │      ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰
│Total amount to be reimbursed                    │      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…
└—————————————————————————————————————————————————…


     Приложение на ________ страницах  Enclosures on ________ pages
————————————————

* По справочнику "BIC directory". By reference book "BIC directory".

** Порядковый номер по Перечню видов доходов, приведенному на экземпляре формы, остающейся у Заявителя. Order number in the List of the types of income, named in the Claimant's copy of the Form.




┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰
│   │ │   │ │ Х │ │   │ │   │ │   │ │   │ │ Х │
└———… └———… └———… └———… └———… └———… └———… └———…

Форма Form 1011DT (1997)                                              Стр. Page 2
——————————————————————————————————————————————————————————————————————————————————————————————————
┌—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│4. Банк получателя платежа                Bank of recipient                                                                      │
│                                                                                                                                 │
│                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                │
│           Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                │
│                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                │
│           Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                        ┌——————————————————————————————————————————————————————————————————————————————————————————————————————‰ │
│           Полный адрес │                                                                                                      │ │
│                        └——————————————————————————————————————————————————————————————————————————————————————————————————————… │
│                                                                                                                                 │
│                                                                                                                                 │
│                                                    Cтрана  ┌———————————————————————————‰             Код           ┌———┬———‰    │
│                                                            │                           │                           │   │   │    │
│Full residential address                                    │                           │                           └———┴———…    │
│                                                    Country └———————————————————————————…             Country code               │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│           Номер счета                    ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰              │
│           Number of Bank account         └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…              │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Заявляю, что:                                                                                                                    │
│                                                                                                                                 │
│I declare that                                                                                                                   │ 

│                                                                                                                                 │
│  указанные доходы не связаны с деятельностью на территории Российской Федерации;                                                │
│                                                                                                                                 │
│  the above mentioned income is not  connected with activities carried in the Russian Federation                                 │
│                                                                                                                                 │
│  на дату начисления, указанную в разделе 3 Заявления, имелось фактическое право на получение                                    │
│  этих доходов                                                                                                                   │
│                                                                                                                                 │
│  on the date of accrued entered in paragraph 3, above, recipient of the above income has being                                  │
│  the beneficial owner                                                                                                           │
│                                                                                                                                 │
│Настоящим подтверждаю достоверность указанных сведений.                                                                          │
│                                                                                                                                 │
│I hereby confirm that the information provided herewith is accurate                                                              │
│                                                                                                                                 │
│┌————————————————————‰                                   ┌——————————————————————————————————————————‰  Должность                 │
││                    │                                   │                                          │  Occupation                │
││                    │                                   └——————————————————————————————————————————…                            │
││                    │ Печать                            ┌——————————————————————————————————————————‰  Имя                       │
││                    │ Stamp                             │                                          │  Name                      │
││                    │                                   └——————————————————————————————————————————…                            │
││                    │                                                                                                           │
││                    │                                                                                                           │
│└————————————————————…                                                                                                           │
│                                                                                                                                 │
│                                                                                                                                 │
│                                            ┌——————————————————‰  Подпись         ┌——┬——┬——┬——┬——┬——‰ Дата                       │
│                                            └——————————————————…  Signature       └——┴——┴——┴——┴——┴——… Date                       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│5. Заполняется уполномоченным налоговым органом иностранного государства                                                         │
│   Note of the foreign Tax authority                                                                                             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Подтверждается, что заявитель действительно являлся в течение _______ лицом с постоянным                                         │
│местопребыванием в                                                                                                               │
│                                                                                                                                 │
│It is hereby confirmed that the claimant during__________________________________________________________________________       │
│was a resident of________________________________________________________________________________________________________       │
│                             название страны/name of the country                                                                 │
│                                                                                                                                 │
│в смысле Соглашения об избежании двойного налогообложения между СССР/Российской Федерацией и                                     │
│in the sense implied in the Double Taxation Convention between the USSR/Russian Federation and                                   │
│__________________________________________________________________________________________________________________________       │
│                              название страны/name of the country                                                                │
│                                                                                                                                 │
│                                         ┌——————‰                                                                                │
│Заявленные доходы подлежат               │      │ налогообложению в стране постоянного                                           │
│The claimed incomes are taxable          └——————… местопребывания                             (отметить     )                    │
│                                         ┌——————‰                                                     ┌———‰                      │
│┌————————————————————‰  не подлежат      │      │ in the country                              (mark   │ Х │ )                    │
││                    │  not taxable      └——————… of residence                                        └———…                      │
││                    │                                                                                                           │
││                    │  Печать      ┌——————————————————————————————————————————‰ Дата и место заполнения                         │
││                    │  Stamp       │                                          │       Date and Place                            │
││                    │              └——————————————————————————————————————————…                                                 │
││                    │              ┌——————————————————————————————————————————‰          Подпись                                │
││                    │              │                                          │          Signature                              │
│└————————————————————…              └——————————————————————————————————————————…                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │ 

│6. Заполняется Госналогинспекцией  Note of the Russian State Tax Office                                                          │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│         Подлежит возврату                                                                                                       │
│                                                ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                            │
│                            Сумма цифрами       └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                            │
│                                                                                                                                 │
│                          ┌————————————————————————————————————————————————————————————————————————————————————‰                 │
│         Сумма прописью   └————————————————————————————————————————————————————————————————————————————————————…                 │
│                                                                                                     ┌—————————————————————————‰ │
│Начальник /Зам.начальника                                                                Печать      │                         │ │
│     Госналогинспекции                                                                               │                         │ │
│┌——————————————————————————‰                       ┌———————————————————————‰                         │                         │ │
││                          │              Подпись  │                       │            Дата         │                         │ │
│└——————————————————————————…                       └———————————————————————…                         │                         │ │
│                                                                                                     │                         │ │
├———————————————————————————————————————————————————————————————————————————————————————————————————— │                         │ │
│Возврат произведен                                                                                   │                         │ │
│                                                                                                     │                         │ │
│                                     ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                           │                         │ │
│                            Сумма    └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                           │                         │ │
│                                                                                                     │                         │ │
│Подпись должностного лица                 Дата                                                       │                         │ │
│┌——————————————————————————‰              ┌———————————————————————‰                                  │                         │ │
││                          │              │                       │                                  │                         │ │
│└——————————————————————————…              └———————————————————————…                                  └—————————————————————————… │
└—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————…




                                                              ┌———————————————————————————————————————————‰
┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰               │  Поля заполняются печатными буквами       │
│   │ │   │ │   │ │ Х │ │ Х │ │   │ │   │ │   │               │  Fields are filled by block letters       │
└———… └———… └———… └———… └———… └———… └———… └———…               └———————————————————————————————————————————…




   В Госналогслужбу России (Управление налогообложения иностранных юридических и физических лиц)
   103381, Москва, ул.Неглинная, 23. Тел.: (095)200-05-52
   To the State Tax Service,  103381, Moscow, Neglinnaya, 23

   Соглашение об избежании двойного налогообложения между Российской Федерацией и
   Double Taxation Convention between the Russian Federation and ________________

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1011DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на возврат налога с дохода от источников            │         За for           │
│ Form 1011DT (1997)                  │                    в Российской Федерации                      │            ┌———‰         │
│ the State Tax Service of Russia     │                 (кроме дивидендов/процентов)                   │         199│   │         │
│                                     │            for a refund of tax withheld in Russia on           │            └———…         │
│                                     │               income (except dividends/interest)               │                          │
│                                     │                                                                │                          │
├—————————————————————————————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН в стране регистрации                              ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰     │
│Identification tax number in country of registration  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│3. Сведения об источнике дохода                                                                                                  │
│   Information about source of income                                                                        Номер**   ┌———┬———‰ │
│                   ┌———————————————————————————————————————————————————————‰                                           │   │   │ │
│Вид дохода         │                                                       │                                 Number**  └———┴———… │
│Type of income     └———————————————————————————————————————————————————————…                                                     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Контрагент                                 Наименование        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│Contractor                                                     └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                               ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│                                           Name in full        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                                                                                                 │
│                                                               ┌——————————————————————————————————————————————————————————————‰  │
│                                           Полный адрес        │                                                              │  │
│                                           Full address        └——————————————————————————————————————————————————————————————…  │
│                                                                                                                                 │
│                                                                                                                                 │ 

│                                           ИНН                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰      │
│                                           Identification tax number   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Договор                                    Номер    ┌————————————————————————————————‰          Дата                             │
│Contract                                            │                                │                  ┌——┬——┬——┬——┬——┬——‰      │
│                                           Number   └————————————————————————————————…          Date    └——┴——┴——┴——┴——┴——…      │
│                                                                                                                                 │
├————————————————————————————————————————————————————————————————————————————————————————————————————┬————————————————————————————┤
│Общая сумма дохода                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │   Код валюты*              │
│до удержания налога                        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                    │   Currency code*           │
│в целых единицах                                                                                    │                            │
│Gross amount of income                     Дата начисления дохода                                   │                            │
│in whole currency units                                                 ┌——┬——┬——┬——┬——┬——‰         │     ┌——┬——┬——‰             │
│                                           Date of accrued of income    └——┴——┴——┴——┴——┴——…         │     └——┴——┴——…             │
│                                                                                                    │                            │
├————————————————————————————————————————————————————————————————————————————————————————————————————┤                            │
│Сумма удержанного налога                   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │                            │
│Tax withheld                               └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                    │                            │
├————————————————————————————————————————————————————————————————————————————————————————————————————┴————————————————————————————┤
│Сумма налога, подлежащая                                                                             Ставка налога               │
│удержанию по Соглашению                                                                              Tax Rate       ┌——┬——‰      │
│Tax under the Treaty                       ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                    └——┴——…      │
│                                           └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                                 │
├—————————————————————————————————————————————————┬———————————————————————————————————————————————————————————————————————————————┤
│Общая сумма налога, подлежащая возврату          │      ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰
│Total amount to be reimbursed                    │      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…
└—————————————————————————————————————————————————…


     Приложение на ________ страницах  Enclosures on ________ pages

————————————————    

* По справочнику "BIC directory". By reference book "BIC directory".

** Порядковый номер по Перечню видов доходов, приведенному на экземпляре формы, остающейся у Заявителя. Order number in the List of the types of income, named in the Claimant's copy of the Form.