Недействующий

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

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


   Заявителю For the Claimant ____________________________________________________

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

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1012DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │ на возврат налога c дивидендов/процентов                       │         За for           │
│ Form 1012DT (1997)                  │          for a refund of tax withheld in Russia on             │            ┌———‰         │ 

│ the State Tax Service of Russia     │                       dividends/interest                       │         199│   │         │
│                                     │                                                                │            └———…         │
│                                     │                                                                │                          │
│                                     │                                                                │                          │
├—————————————————————————————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН                            ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                            │
│Identification tax number      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                            │
│                                                                                                                                 │
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌——————————————————————————————————————————————————————————-——————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│3. Инвестиции                                                                                   Код валюты*     ┌——┬——┬——‰       │
│   Capital investment                                                                                           │  │  │  │       │
│                                                                                                                └——┴——┴——…       │
│                                                                                                Currency code*                   │
│   Описание инвестиции          ┌———————————————————————————————————————————————————————————‰                   ┌——┬——┬——‰       │
│   Description of investment    │                                                           │                   │  │  │  │       │
│                                └———————————————————————————————————————————————————————————…                   └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Наименование должника и его адрес ┌————————————————————————————————————————————————————————————————————————————————‰          │
│   Name of debtor, address           │                                                                                │          │
│                                     └————————————————————————————————————————————————————————————————————————————————…          │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Число акций         ┌——┬——┬——┬——┬——┬——‰        Общий номинал     ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰    Дата приобретения         │
│   Number of shares    └——┴——┴——┴——┴——┴——…        Total par value   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…    Data of acquisition       │
│                                                                                                                                 │
│                                                                                                       ┌——┬——┬——┬——┬——┬——‰       │
│                                                                                                       └——┴——┴——┴——┴——┴——…       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————‰                           │
│                                                                                                     │                           │
│   Дата начисления дивидендов, процентов                    ┌——┬——┬——┬——┬——┬——‰                      │                           │
│   Date of accrued of dividends, interest                   └——┴——┴——┴——┴——┴——…                      │                           │
├———————————————————————————————————————————————————————————┬—————————————————————————————————————————┴———————————————————————————┤
│                                                           │                                                                     │ 

│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
│———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————┤
│Сумма удержанного налога        ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога       ┌——┬——‰               │
│Amount of Tax withheld          └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax Rate            └——┴——…               │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Сумма налога по Соглашению      ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога по Соглашению               │
│Amount of Tax under the Treaty  └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax rate 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".



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

Форма Form 1012DT (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 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 Уполномоченный  налоговый орган Заявителя
   For Claimants's foreign Tax authority ______________________________________________________________

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

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1012DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на возврат налога дивидендов/процентов              │         За for           │
│ Form 1012DT (1997)                  │           for a refund of tax withheld in Russia on            │            ┌———‰         │ 

│ the State Tax Service of Russia     │                      dividends/interest                        │         199│   │         │
│                                     │                                                                │            └———…         │
│                                     │                                                                │                          │
│                                     │                                                                │                          │
├—————————————————————————————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН                            ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                            │
│Identification tax number      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                            │
│                                                                                                                                 │
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌——————————————————————————————————————————————————————————-——————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│3. Инвестиции                                                                                   Код валюты*     ┌——┬——┬——‰       │
│   Capital investment                                                                                           │  │  │  │       │
│                                                                                                Currency code*  └——┴——┴——…       │
│                                                                                                                                 │
│   Описание инвестиции          ┌———————————————————————————————————————————————————————————‰                   ┌——┬——┬——‰       │
│   Description of investment    │                                                           │                   │  │  │  │       │
│                                └———————————————————————————————————————————————————————————…                   └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Наименование должника и его адрес ┌————————————————————————————————————————————————————————————————————————————————‰          │
│   Name of debtor, address           │                                                                                │          │
│                                     └————————————————————————————————————————————————————————————————————————————————…          │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Число акций         ┌——┬——┬——┬——┬——┬——‰        Общий номинал     ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰    Дата приобретения         │
│   Number of shares    └——┴——┴——┴——┴——┴——…        Total par value   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…    Data of acquisition       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————‰                           │
│                                                                                                     │  ┌——┬——┬——┬——┬——┬——‰      │
│   Дата начисления дивидендов, процентов                    ┌——┬——┬——┬——┬——┬——‰                      │  └——┴——┴——┴——┴——┴——…      │
│   Date of accrued of dividends, interest                   └——┴——┴——┴——┴——┴——…                      │                           │
├———————————————————————————————————————————————————————————┬—————————————————————————————————————————┴———————————————————————————┤
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │ 

├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
├———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————┤
│Сумма удержанного налога        ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога       ┌——┬——‰               │
│Amount of Tax withheld          └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax Rate            └——┴——…               │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Сумма налога по Соглашению      ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога по Соглашению               │
│Amount of Tax under the Treaty  └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax rate 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".



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

Форма Form 1012DT (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 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 │ │   │ │ 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 1012DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на возврат налога c дивидендов/процентов            │         За for           │
│ From 1012DT (1997)                  │           for a refund of tax withheld in Russia on            │            ┌———‰         │
│ the State Tax Service of Russia     │                      dividends/interest                        │         199│   │         │
│                                     │                                                                │            └———…         │
│                                     │                                                                │                          │ 

│                                     │                                                                │                          │
├—————————————————————————————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН                            ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                            │
│Identification tax number      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                            │
│                                                                                                                                 │
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————-———————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│3. Инвестиции                                                                                   Код валюты*     ┌——┬——┬——‰       │
│   Capital investment                                                                                           │  │  │  │       │
│                                                                                                Currency code*  └——┴——┴——…       │
│                                                                                                                                 │
│   Описание инвестиции          ┌———————————————————————————————————————————————————————————‰                   ┌——┬——┬——‰       │
│   Description of investment    │                                                           │                   │  │  │  │       │
│                                └———————————————————————————————————————————————————————————…                   └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Наименование должника и его адрес ┌————————————————————————————————————————————————————————————————————————————————‰          │
│   Name of debtor, address           │                                                                                │          │
│                                     └————————————————————————————————————————————————————————————————————————————————…          │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Число акций         ┌——┬——┬——┬——┬——┬——‰        Общий номинал     ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰    Дата приобретения         │
│   Number of shares    └——┴——┴——┴——┴——┴——…        Total par value   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…    Data of acquisition       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————‰                           │
│                                                                                                     │  ┌——┬——┬——┬——┬——┬——‰      │
│   Дата начисления дивидендов, процентов                    ┌——┬——┬——┬——┬——┬——‰                      │  └——┴——┴——┴——┴——┴——…      │
│   Date of accrued of dividends, interest                   └——┴——┴——┴——┴——┴——…                      │                           │
├———————————————————————————————————————————————————————————┬—————————————————————————————————————————┴———————————————————————————┤
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │ 

│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
├———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————┤
│Сумма удержанного налога        ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога       ┌——┬——‰               │
│Amount of Tax withheld          └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax Rate            └——┴——…               │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Сумма налога по Соглашению      ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога по Соглашению               │
│Amount of Tax under the Treaty  └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax rate 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".



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

Форма Form 1012DT (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 │ │ 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 Сonvention between the Russian Federation and ____________________________

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1012DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на возврат налога c дивидендов/процентов            │         За for           │
│ From 1012DT (1997)                  │           for a refund of tax withheld in Russia on            │            ┌———‰         │
│ the State Tax Service of Russia     │                      dividends/interest                        │         199│   │         │
│                                     │                                                                │            └———…         │
│                                     │                                                                │                          │
│                                     │                                                                │                          │
├—————————————————————————————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │ 

│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН                            ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                            │
│Identification tax number      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                            │
│                                                                                                                                 │
│                                                                                                                                 │
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│3. Инвестиции                                                                                   Код валюты*     ┌——┬——┬——‰       │
│   Capital investment                                                                                           │  │  │  │       │
│                                                                                                Currency Code*  └——┴——┴——…       │
│                                                                                                                                 │
│   Описание инвестиции          ┌———————————————————————————————————————————————————————————‰                   ┌——┬——┬——‰       │
│   Description of investment    │                                                           │                   │  │  │  │       │
│                                └———————————————————————————————————————————————————————————…                   └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Наименование должника и его адрес ┌————————————————————————————————————————————————————————————————————————————————‰          │
│   Name of debtor, address           │                                                                                │          │
│                                     └————————————————————————————————————————————————————————————————————————————————…          │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   Число акций         ┌——┬——┬——┬——┬——┬——‰        Общий номинал     ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰    Дата приобретения         │
│   Number of shares    └——┴——┴——┴——┴——┴——…        Total par value   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…    Data of acquisition       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————‰                           │
│                                                                                                     │  ┌——┬——┬——┬——┬——┬——‰      │
│   Дата начисления дивидендов, процентов                    ┌——┬——┬——┬——┬——┬——‰                      │  └——┴——┴——┴——┴——┴——…      │
│   Date of accrued of dividends, interest                   └——┴——┴——┴——┴——┴——…                      │                           │
├———————————————————————————————————————————————————————————┬—————————————————————————————————————————┴———————————————————————————┤
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │ 

│other companies                                            │ Others interest                                                     │
├———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————┤
│Сумма удержанного налога        ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога       ┌——┬——‰               │
│Amount of Tax withheld          └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax Rate            └——┴——…               │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Сумма налога по Соглашению      ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                           Ставка налога по Соглашению               │
│Amount of Tax under the Treaty  └——┴——┴——┴——┴——┴——┴——┴——┴——…                           Tax rate 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".




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

Форма Form 1012DT (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                              │
│└————————————————————…              └——————————————————————————————————————————…                                                 │
└—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————…



┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰
│   │ │   │ │   │ │ Х │ │ Х │ │   │ │ Х │ │   │
└———… └———… └———… └———… └———… └———… └———… └———…
┌—————————————————————————————————————————————————————————————————————————————————‰
│Приложение к Форме 1012DT (1997)                                                 │
│Enclosure to the form 1012DT (1997)                                              │
│┌—————————————————————————————————————————————————‰   наименование иностранного  │
││                                                 │   юридического лица          │
││                                                 │   name of foreign entity     │
│└—————————————————————————————————————————————————…                              │
│                                                                                 │
│┌—————————————————————————‰                           Дата (из раздела 4)        │
││                         │     ┌——┬——┬——┬——┬——┬——‰   Date (from paragraph 4)    │  Лист
│└—————————————————————————…     └——┴——┴——┴——┴——┴——…                              │  Sheet N
└—————————————————————————————————————————————————————————————————————————————————…
┌——┬——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│1.│ Описание инвестиции            ┌—————————————————————————————————————————————————————————————————‰                           │
├——… Description of investment      │                                                                 │          ┌——┬——┬——‰       │
│                                   └—————————————————————————————————————————————————————————————————…          └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                           ┌—————————————————————————————————————————————————————————————————‰                   │
│    Наименование должника и его адрес      │                                                                 │                   │
│    Name of debtor, address                └—————————————————————————————————————————————————————————————————…                   │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————│
│   Число акций      ┌——┬——┬——┬——┬——┬——‰  Общий номинал   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  Дата приобретения   ┌——┬——┬——┬——┬——┬——‰│
│   Number of shares └——┴——┴——┴——┴——┴——…  Total par value └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  Data of acquisition └——┴——┴——┴——┴——┴——…│
│                                                                                                                                 │
├——————————————————————————————————————————————————————————————————————————————————————————┬——————————————————————————————————————┤
│                                                                                          │Код валюты     ┌——┬——┬—-‰             │
│   Дата начисления дивидендов, процентов     ┌——┬——┬——┬——┬——┬——‰                          │Currency code  └——┴——┴——…             │
│   Date of accrued of dividends, interest    └——┴——┴——┴——┴——┴——…                          │                                      │
├———————————————————————————————————————————————————————————┬——————————————————————————————┴——————————————————————————————————————│
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
└———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————…

┌——┬——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│2.│ Описание инвестиции            ┌—————————————————————————————————————————————————————————————————‰                           │
├——… Description of investment      │                                                                 │          ┌——┬——┬——‰       │
│                                   └—————————————————————————————————————————————————————————————————…          └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                           ┌—————————————————————————————————————————————————————————————————‰                   │
│    Наименование должника и его адрес      │                                                                 │                   │
│    Name of debtor, address                └—————————————————————————————————————————————————————————————————…                   │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————│
│   Число  акций     ┌——┬——┬——┬——┬——┬——‰  Общий номинал   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  Дата приобретения   ┌——┬——┬——┬——┬——┬——‰│
│   Number of shares └——┴——┴——┴——┴——┴——…  Total par value └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  Data of acquisition └——┴——┴——┴——┴——┴——…│
│                                                                                                                                 │ 

├——————————————————————————————————————————————————————————————————————————————————————————┬——————————————————————————————————————┤
│                                                                                          │Код валюты     ┌——┬——┬——‰             │
│   Дата начисления дивидендов, процентов     ┌——┬——┬——┬——┬——┬——‰                          │Currency code  └——┴——┴——…             │
│   Date of accrued of dividends, interest    └——┴——┴——┴——┴——┴——…                          │                                      │
├———————————————————————————————————————————————————————————┬——————————————————————————————┴——————————————————————————————————————│
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
└———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————…

┌——┬——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│3.│ Описание инвестиции            ┌—————————————————————————————————————————————————————————————————‰                           │
├——… Description of investment      │                                                                 │          ┌——┬——┬——‰       │
│                                   └—————————————————————————————————————————————————————————————————…          └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                           ┌—————————————————————————————————————————————————————————————————‰                   │
│    Наименование должника и его адрес      │                                                                 │                   │
│    Name of debtor, address                └—————————————————————————————————————————————————————————————————…                   │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————│
│   Число акций      ┌——┬——┬——┬——┬——┬——‰  Общий номинал   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  Дата приобретения   ┌——┬——┬——┬——┬——┬——‰│
│   Number of shares └——┴——┴——┴——┴——┴——…  Total par value └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  Data of acquisition └——┴——┴——┴——┴——┴——…│
│                                                                                                                                 │
├——————————————————————————————————————————————————————————————————————————————————————————┬——————————————————————————————————————┤
│                                                                                          │Код валюты     ┌——┬——┬——‰             │
│   Дата начисления дивидендов, процентов     ┌——┬——┬——┬——┬——┬——‰                          │Currency code  └——┴——┴——…             │
│   Date of accrued of dividends, interest    └——┴——┴——┴——┴——┴——…                          │                                      │
├———————————————————————————————————————————————————————————┬——————————————————————————————┴——————————————————————————————————————│
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
└———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————…



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

Форма Form 1012DT (1997)                                           стр.page 2
——————————————————————————————————————————————————————————————————————————————————————
┌——┬——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│4.│ Описание инвестиции            ┌—————————————————————————————————————————————————————————————————‰                           │
├——… Description of investment      │                                                                 │          ┌——┬——┬——‰       │
│                                   └—————————————————————————————————————————————————————————————————…          └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                           ┌—————————————————————————————————————————————————————————————————‰                   │
│    Наименование должника и его адрес      │                                                                 │                   │ 

│    Name of debtor, address                └—————————————————————————————————————————————————————————————————…                   │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————│
│   Количество акций ┌——┬——┬——┬——┬——┬——‰  Общий номинал   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  Дата приобретения   ┌——┬——┬——┬——┬——┬——‰│
│   Number of shares └——┴——┴——┴——┴——┴——…  Total par value └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  Data of acquisition └——┴——┴——┴——┴——┴——…│
│                                                                                                                                 │
├——————————————————————————————————————————————————————————————————————————————————————————┬——————————————————————————————————————┤
│                                                                                          │Код валюты     ┌——┬——┬——‰             │
│   Дата начисления дивидендов, процентов     ┌——┬——┬——┬——┬——┬——‰                          │Currency code  └——┴——┴——…             │
│   Date of accrued of dividends, interest    └——┴——┴——┴——┴——┴——…                          │                                      │
├———————————————————————————————————————————————————————————┬——————————————————————————————┴——————————————————————————————————————│
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
└———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————…

┌——┬——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│5.│ Описание инвестиции            ┌—————————————————————————————————————————————————————————————————‰                           │
├——… Description of investment      │                                                                 │          ┌——┬——┬——‰       │
│                                   └—————————————————————————————————————————————————————————————————…          └——┴——┴——…       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                           ┌———————————————————————————————————————————————————————————-—————‰                   │
│    Наименование должника и его адрес      │                                                                 │                   │
│    Name of debtor, address                └—————————————————————————————————————————————————————————————————…                   │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————│
│   Число акций      ┌——┬——┬——┬——┬——┬——‰  Общий номинал   ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  Дата приобретения   ┌——┬——┬——┬——┬——┬——‰│
│   Number of shares └——┴——┴——┴——┴——┴——…  Total par value └——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  Data of acquisition └——┴——┴——┴——┴——┴——…│
│                                                                                                                                 │
├——————————————————————————————————————————————————————————————————————————————————————————┬——————————————————————————————————————┤
│                                                                                          │Код валюты     ┌——┬——┬——‰             │
│   Дата начисления дивидендов, процентов     ┌——┬——┬——┬——┬——┬——‰                          │Currency code  └——┴——┴——…             │
│   Date of accrued of dividends, interest    └——┴——┴——┴——┴——┴——…                          │                                      │
├———————————————————————————————————————————————————————————┬——————————————————————————————┴——————————————————————————————————————│
│                                                           │                                                                     │
│Дивиденды за акцию                                         │ Ставка  процента                                                    │
│                           A ┌——┬——┬——┬——┬——┬——‰           │                       D   ┌——┬——‰                                   │
│Dividends per share          └——┴——┴——┴——┴——┴——…           │ Interest rate (%)         └——┴——…                                   │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от дочерней компании                             │ Проценты по государственным                                         │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │ ценным бумагам   E  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from subsidiary  B └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│                                                           │ Interest on government bonds                                        │
├———————————————————————————————————————————————————————————┼—————————————————————————————————————————————————————————————————————┤
│Дивиденды от других компаний                               │ Другие проценты                                                     │
│                             ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰  │                  F  ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰                    │
│Dividends from             С └——┴——┴——┴——┴——┴——┴——┴——┴——…  │                     └——┴——┴——┴——┴——┴——┴——┴——┴——…                    │
│other companies                                            │ Others interest                                                     │
└———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————…
┌———————————————————————————————————————————————————————————┬—————————————————————————————————————————————————————————————————————‰
│Cумма удержанного налога                                   │ Ставка и сумма налога по Соглашению                                 │
│(по итогам к разделам A,B,C,E,F)                           │ Tax Rate and amount of Tax under Treaty                             │
│Amount of Tax withheld (on Total of line A,B,C,E,F)        │                                                                     │ 

│                                                           │                                                                     │
│                                          Ставка           │                                           Ставка                    │
│                                          Tax Rate         │                                           Tax Rate                  │
│ ┌———‰                                   ┌——┬——‰           │   ┌———‰                                   ┌——┬——‰                   │
│ │ A │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │           │   │ A │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │                   │
│ └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…           │   └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…                   │
│                                                           │                                                                     │
│ ┌———‰                                   ┌——┬——‰           │   ┌———‰                                   ┌——┬——‰                   │
│ │ B │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │           │   │ B │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │                   │
│ └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…           │   └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…                   │
│                                                           │                                                                     │
│ ┌———‰                                   ┌——┬——‰           │   ┌———‰                                   ┌——┬——‰                   │
│ │ C │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │           │   │ C │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │                   │
│ └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…           │   └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…                   │
│                                                           │                                                                     │
│ ┌———‰                                   ┌——┬——‰           │   ┌———‰                                   ┌——┬——‰                   │
│ │ E │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │           │   │ E │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │                   │
│ └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…           │   └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…                   │
│                                                           │                                                                     │
│ ┌———‰                                   ┌——┬——‰           │   ┌———‰                                   ┌——┬——‰                   │
│ │ F │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │           │   │ F │    ┌——┬——┬——┬——┬——┬——┬——┬——┬——‰   │  │  │                   │
│ └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…           │   └———…    └——┴——┴——┴——┴——┴——┴——┴——┴——…   └——┴——…                   │
└———————————————————————————————————————————————————————————┴—————————————————————————————————————————————————————————————————————…