Недействующий

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

                                                               ┌————————————————————————————————————‰
┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰ ┌———‰                │ Поля заполняются печатными буквами │
│   │ │   │ │ Х │ │   │ │ 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 between the Russian Federation and ____________________________

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1013DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │       на предварительное освобождение от налогообложения       │         на for           │
│ Form 1013DT (1997)                  │       пассивных доходов от источников в Российской Федерации   │            ┌———‰         │
│ the State Tax Service of Russia     │       for an exemption incomes sourced in Russia before        │         199│   │         │
│                                     │                        the payment is made                     │            └———…         │
│                                     │                                                                │                          │
│                                     │                                                                │                          │
├————————————————————————┬————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
│                                                                                                                                 │
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └——————————————————————————————————————————————————————————————————————————————————————————————————————-——…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН в стране регистрации                              ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰     │
│Identification tax number in country of registration  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…     │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│3. Сведения об источнике дохода                                                                                                  │
│   Information about source of income                                                                        Номер**   ┌———┬———‰ │
│                   ┌———————————————————————————————————————————————————————‰                                           │   │   │ │
│Вид дохода         │                                                       │                                 Number**  └———┴———… │
│Type of income     └———————————————————————————————————————————————————————…                                                     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Контрагент                                 Наименование        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│Contractor                                                     └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │ 

│                                                               ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│                                           Name in full        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                                                                                                 │
│                                                               ┌——————————————————————————————————————————————————————————————‰  │
│                                           Полный адрес        │                                                              │  │
│                                           Full address        └——————————————————————————————————————————————————————————————…  │
│                                                                                                                                 │
│                                                                                                                                 │
│                                           ИНН                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰      │
│                                           Identification tax number   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Договор                                    Номер    ┌————————————————————————————————‰          Дата                             │
│Contract                                            │                                │                  ┌——┬——┬——┬——┬——┬——‰      │
│                                           Number   └————————————————————————————————…          Date    └——┴——┴——┴——┴——┴——…      │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————┬———————————————————————————————————┤
│                                        ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬————‰   │                                   │
│Сумма дохода в целых единицах***     А  └———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴————…   │            Код валюты*            │
│Total income in whole                                                                        │           Currency code*          │
│currency units***                                                                            │                                   │
│                                                                                             │                                   │
├—————————————————————————————————————————————————————————————————————————————————————————————┤           ┌———┬———┬———‰           │
│Сумма налога, подлежащая                                                                     │           └———┴———┴———…           │
│удержанию по основной ставке            ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬————‰   │                                   │
│Amount of tax to be withheld         B  └———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴————…   │                                   │
│at basic rate                                                                                │                                   │
├———————————————————————————————————————————————————————┬—————————————————————————————————————┴———————————————————————————————————┤
│Cумма налога, подлежащая                                                                                                         │
│удержанию по Соглашению                 ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬————‰               Ставка налога           │
│Tax under the Treaty                 C  └———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴————…                Tax Rate               │
│                                                                                                           ┌———┬———‰             │
│                                                                                                           └———┴———…             │
├———————————————————————————————————————————————————————┬—————————————————————————————————————————————————————————————————————————…
│                                                       │
│Общая сумма налога, не подлежащая удержанию            │
│(стр.B - стр.С)                                        │ ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———‰
│Total tax not subject to withholding                   │ └———┴———┴———┴———┴———┴———┴———┴———┴———┴———…
│(line B - line C)                                      │
└———————————————————————————————————————————————————————…



     Приложение на______ страницах     Enclosures on ________ pages


————————————————

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

** Порядковый номер по Перечню видов доходов на стр.2. Order number in the List of the types of income on page 2.

*** Может быть указана приблизительная сумма. Can be specified an approximate ammount.


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


Форма Form 1013DT (1997)                              Стр.Page 2

┌—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│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                                 │
│                                                                                                                                 │
│  получатель имеет фактическое право на получение этих доходов;                                                                  │
│                                                                                                                                 │
│  the recipient of the above income is being the beneficial                                                                      │
│                                                                                                                                 │
│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                                                       │
│                                                                                                                                 │
│                                                                                                                                 │
│4. 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                              │
│└————————————————————…              └——————————————————————————————————————————…                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Перечень видов доходов   List of types of income                                                                                 │
├————┬———————————————————————————————————————————————————————┬————————————————————————————————————————————————————————————————————┤
│N   │                 Наименование                          │           Type                                                     │
├————┼———————————————————————————————————————————————————————┼————————————————————————————————————————————————————————————————————┤
│01  │      Дивиденды                                        │    Dividends                                                       │
│    │                                                       │                                                                    │
│02  │      Доходы от долевого участия                       │    Income from underwriting shares                                 │
│    │                                                       │                                                                    │
│03  │      Доходы от инвестиционных фондов и т.п.           │    Income from investment funds etc.                               │
│    │                                                       │                                                                    │
│04  │      Процентный доход по корреспондентским счетам     │    Interest from corresponding accounts                            │
│    │                                                       │                                                                    │
│05  │      Процентный доход по кредитам                     │    Interest from credits                                           │
│    │                                                       │                                                                    │
│06  │      Процентный доход по депозитам                    │    Interest from deposits                                          │
│    │                                                       │                                                                    │
│07  │      Процентный доход по корпоративным облигациям     │    Interest from corporate bonds                                   │
│    │                                                       │                                                                    │
│08  │      Процентный доход по государственным облигациям   │    Interest from state bonds                                       │
│    │                                                       │                                                                    │ 

│09  │      Процентный (дисконтный) доход по векселям        │    Interest (discount) from notes                                  │
│    │                                                       │                                                                    │
│10  │      Процентный доход по другим ценным бумагам        │    Interest from other paper                                       │
│    │                                                       │                                                                    │
│11  │      Процентный доход от штрафов и пени               │    Interest from penalties                                         │
│    │                                                       │                                                                    │
│12  │      Лицензионные платежи (роялти)                    │    Royalties                                                       │
│    │                                                       │                                                                    │
│13  │      Доходы от аренды (лизинга) движимого             │    Income from  leasings of movable                                │
│    │      имущества                                        │    property                                                        │
│    │                                                       │                                                                    │
│14  │      Доходы от аренды (лизинга) недвижимого имущества │    Income from leasings of real estate                             │
│    │                                                       │                                                                    │
│15  │      Премии по прямому страхованию и сострахованию    │    Premiums from  direct insurance and                             │
│    │                                                       │    coinsurance                                                     │
│    │                                                       │                                                                    │
│16  │      Премии по перестрахованию                        │    Premiums from reinsurance                                       │
│    │                                                       │                                                                    │
│17  │      Проценты на депо премий                          │    Interest on  depo of premiums                                   │
│    │                                                       │                                                                    │
│18  │      Другие доходы                                    │    Other income                                                    │
└————┴———————————————————————————————————————————————————————┴————————————————————————————————————————————————————————————————————…





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



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

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

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1013DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на предварительное освобождение от налогообложения  │         на for           │ 

│ Form 1013DT (1997)                  │         пассивных доходов от источников в Российской Федерации │            ┌———‰         │
│ the State Tax Service of Russia     │            for an exemption incomes sourced in Russia before   │         199│   │         │
│                                     │                      the payment is made                       │            └———…         │
│                                     │                                                                │                          │
│                                     │                                                                │                          │
├—————————————————————————————————————┴————————————————————————————————————————————————————————————————┴——————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН в стране регистрации       ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                            │
│Identification tax number      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                            │
│in country of registration                                                                                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│3. Сведения об источнике дохода                                                                                                  │
│   Information about source of income                                                                        Номер**   ┌———┬———‰ │
│                   ┌———————————————————————————————————————————————————————‰                                           │   │   │ │
│Вид дохода         │                                                       │                                 Number**  └———┴———… │
│Type of income     └———————————————————————————————————————————————————————…                                                     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Контрагент                                 Наименование        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│Contractor                                                     └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                               ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│                                           Name in full        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                                                                                                 │
│                                                               ┌——————————————————————————————————————————————————————————————‰  │
│                                           Полный адрес        │                                                              │  │
│                                           Full address        └——————————————————————————————————————————————————————————————…  │
│                                                                                                                                 │
│                                                                                                                                 │
│                                           ИНН                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰      │
│                                           Identification tax number   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Договор                                    Номер    ┌————————————————————————————————‰          Дата                             │
│Contract                                            │                                │                  ┌——┬——┬——┬——┬——┬——‰      │
│                                           Number   └————————————————————————————————…          Date    └——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————┬———————————————————————————————————┤

│                                        ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬————‰   │                                   │
│Сумма дохода в целых единицах***     А  └———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴————…   │            Код валюты*            │
│Total income in whole                                                                        │           Currency code*          │
│currency units***                                                                            │                                   │
│                                                                                             │                                   │
├—————————————————————————————————————————————————————————————————————————————————————————————┤           ┌———┬———┬———‰           │
│Сумма налога, подлежащая                                                                     │           └———┴———┴———…           │
│удержанию по основной ставке            ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬————‰   │                                   │
│Amount of tax to be withheld         B  └———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴————…   │                                   │
│at basic rate                                                                                │                                   │
├—————————————————————————————————————————————————————————————————————————————————————————————┴———————————————————————————————————┤
│Сумма налога, подлежащая                                                                                 Ставка налога           │
│удержанию по Соглашению                 ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬————‰                  Tax Rate             │
│Tax under the Treaty                 C  └———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴————…                  ┌———┬———‰            │
│                                                                                                            └———┴———…            │   
├———————————————————————————————————————————————————————┬—————————————————————————————————————————————————————————————————————————…
│Общая сумма налога, не подлежащая удержанию            │
│(стр.B - стр.С)                                        │ ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———‰
│Total tax not subject to withholding                   │ └———┴———┴———┴———┴———┴———┴———┴———┴———┴———…
│(line B - line C)                                      │
└———————————————————————————————————————————————————————…

     Приложение на _________ страницах      Enclosures on ___________ pages

————————————————

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

** Порядковый номер по Перечню видов доходов на стр.2. Order number in the List of the types of income on page 2.

*** Может быть указана приблизительная сумма. Can be specified an approximate ammount.



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


Форма Form 1013DT (1997)                              Стр.Page 2

┌—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│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                                 │
│                                                                                                                                 │
│  получатель имеет фактическое право на получение этих доходов;                                                                  │
│                                                                                                                                 │
│  the recipient of the above income is  being the beneficial                                                                     │                                    │
│                                                                                                                                 │
│                                                                                                                                 │
│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                                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————│
│                                                                                                                                 │
│4. 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                              │
│└————————————————————…              └——————————————————————————————————————————…                                                 │
├———————————————————————————————————————————————————————┬—————————————————————————————————————————————————————————————————————————…
│Перечень видов доходов   List of types of income       │
├————┬——————————————————————————————————————————————————┴————┬————————————————————————————————————————————————————————————————————‰
│N   │                 Наименование                          │           Type                                                     │
├————┼———————————————————————————————————————————————————————┼————————————————————————————————————————————————————————————————————┤
│01  │      Дивиденды                                        │    Dividends                                                       │                 │
│    │                                                       │                                                                    │ 

│02  │      Доходы от долевого участия                       │    Income from underwriting shares                                 │
│    │                                                       │                                                                    │
│03  │      Доходы от инвестиционных фондов и т.п.           │    Income from investment funds etc.                               │
│    │                                                       │                                                                    │
│04  │      Процентный доход по корреспондентским счетам     │    Interest from corresponding accounts                            │
│    │                                                       │                                                                    │
│05  │      Процентный доход по кредитам                     │    Interest from credits                                           │
│    │                                                       │                                                                    │
│06  │      Процентный доход по депозитам                    │    Interest from deposits                                          │
│    │                                                       │                                                                    │
│07  │      Процентный доход по корпоративным облигациям     │    Interest from corporate bonds                                   │
│    │                                                       │                                                                    │
│08  │      Процентный доход по государственным облигациям   │    Interest from state bonds                                       │
│    │                                                       │                                                                    │
│09  │      Процентный (дисконтный) доход по векселям        │    Interest (discount) from notes                                  │
│    │                                                       │                                                                    │
│10  │      Процентный доход по другим ценным бумагам        │    Interest from other paper                                       │
│    │                                                       │                                                                    │
│11  │      Процентный доход от штрафов и пени               │    Interest from penalties                                         │
│    │                                                       │                                                                    │
│12  │      Лицензионные платежи (роялти)                    │    Royalties                                                       │
│    │                                                       │                                                                    │
│13  │      Доходы от аренды (лизинга) движимого             │    Income from  leasings of movable                                │
│    │      имущества                                        │    property                                                        │
│    │                                                       │                                                                    │
│14  │      Доходы от аренды (лизинга) недвижимого имущества │    Income from leasings of real estate                             │
│    │                                                       │                                                                    │
│15  │      Премии по прямому страхованию и сострахованию    │    Premiums from  direct insurance and                             │
│    │                                                       │    coinsurance                                                     │
│    │                                                       │                                                                    │
│16  │      Премии по перестрахованию                        │    Premiums from reinsurance                                       │
│    │                                                       │                                                                    │
│17  │      Проценты на депо премий                          │    Interest on  depo of premiums                                   │
│    │                                                       │                                                                    │
│18  │      Другие доходы                                    │    Other income                                                    │
└————┴———————————————————————————————————————————————————————┴————————————————————————————————————————————————————————————————————…


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



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

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

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1013DT (1997)                 │                   ЗАЯВЛЕНИЕ CLAIM                              │                          │
│ Госналогслужба России               │       на предварительное освобождение от налогообложения       │         на for           │
│ Form 1013DT (1997)                  │    пассивных доходов от источников в Российской Федерации      │            ┌———‰         │
│ the State Tax Service of Russia     │       for an exemption incomes sourced in Russia before        │         199│   │         │
│                                     │                 the payment is made                            │            └———…         │
│                                     │                                                                │                          │
│                                     │                                                                │                          │
├—————————————————————————————————————┼————————————————————————————————————————————————————————————————┴——————————————————————————┤
│ Место штампа "ПОЛУЧЕНО"             │  Отметка Госналогинспекции о получении Уведомления                                        │
├—————————————————————————————————————┴———————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤

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

├———————————————————————————————————————————————————————┬—————————————————————————————————————————————————————————————————————————…
│Общая сумма налога, не подлежащая удержанию            │
│(стр.B - стр.С)                                        │ ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———‰
│Total tax not subject to withholding                   │ └———┴———┴———┴———┴———┴———┴———┴———┴———┴———…
│(line B - line C)                                      │
└———————————————————————————————————————————————————————…

     Приложение на _________ страницах      Enclosures on ___________ pages

————————————————

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

** Порядковый номер по Перечню видов доходов на стр.2. Order number in the List of the types of income on page 2.

*** Может быть указана приблизительная сумма. Can be specified an approximate ammount.



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


Форма Form 1013DT (1997)                              Стр.Page 2

┌—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————‰
│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                                 │
│                                                                                                                                 │
│  получатель имеет фактическое право на получение этих доходов;                                                                  │
│                                                                                                                                 │
│  the recipient of the above income is  being the beneficial                                                                     │                                    │
│                                                                                                                                 │
│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                                                       │
│                                                                                                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│4. 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                              │
│└————————————————————…              └——————————————————————————————————————————…                                                 │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│5. Заполняется Госналогинспекцией   Note of Russian State Tax Office                                                             │
├——————————————————————————————————————————————————————————————————————————————————————————————————————————————┬——————————————————┤
│С декларируемого в разделе 3 дохода:                                                                          │                  │
│                                                                                                              │                  │
├—┬—————————————————————————————‰                Начальник/Зам.начальника                                      │                  │
│А│ Налог не подлежит удержанию │                Госналогинспекции                                             │                  │
├—┴—————————————————————————————…                                                                              │                  │
│                                                                                                              │                  │
│                                                 Подпись                        Дата                          │                  │
│                                                ┌————————————————————————‰                                    │                  │
│                                                │                        │     ┌——┬——┬——┬——┬——┬——‰            │                  │
│                                                └————————————————————————…     └——┴——┴——┴——┴——┴——…            │                  │
├——————————————————————————————————————————————————————————————————————————————————————————————————————————————┼——————————————————┤
│                                                                                                              │                  │
├—┬—————————————————————————————————————‰        Начальник/Зам.начальника                                      │                  │
│B│ Налог не подлежит удержанию ┌——┬——‰ │        Госналогинспекции                                             │                  │
│ │ по ставке                   └——┴——… │                                                                      │                  │
├—┴—————————————————————————————————————…                                                                      │                  │
│                                                 Подпись                        Дата                          │ Печать           │
│                                                ┌————————————————————————‰                                    │┌————————————————‰│
│                                                │                        │     ┌——┬——┬——┬——┬——┬——‰            ││                ││
│                                                └————————————————————————…     └——┴——┴——┴——┴——┴——…            ││                ││ 

│                                                                                                              │└————————————————…│
├———————————————————————————————————————————————————————┬——————————————————————————————————————————————————————┴——————————————————…
│Перечень видов доходов   List of types of income       │
├————┬——————————————————————————————————————————————————┴————┬————————————————————————————————————————————————————————————————————‰
│N   │                 Наименование                          │           Type                                                     │
├————┼———————————————————————————————————————————————————————┼————————————————————————————————————————————————————————————————————┤
│01  │      Дивиденды                                        │    Dividends                                                       │                 │
│    │                                                       │                                                                    │
│02  │      Доходы от долевого участия                       │    Income from underwriting shares                                 │
│    │                                                       │                                                                    │
│03  │      Доходы от инвестиционных фондов и т.п.           │    Income from investment funds etc.                               │
│    │                                                       │                                                                    │
│04  │      Процентный доход по корреспондентским счетам     │    Interest from corresponding accounts                            │
│    │                                                       │                                                                    │
│05  │      Процентный доход по кредитам                     │    Interest from credits                                           │
│    │                                                       │                                                                    │
│06  │      Процентный доход по депозитам                    │    Interest from deposits                                          │
│    │                                                       │                                                                    │
│07  │      Процентный доход по корпоративным облигациям     │    Interest from corporate bonds                                   │
│    │                                                       │                                                                    │
│08  │      Процентный доход по государственным облигациям   │    Interest from state bonds                                       │
│    │                                                       │                                                                    │
│09  │      Процентный (дисконтный) доход по векселям        │    Interest (discount) from notes                                  │
│    │                                                       │                                                                    │
│10  │      Процентный доход по другим ценным бумагам        │    Interest from other paper                                       │
│    │                                                       │                                                                    │
│11  │      Процентный доход от штрафов и пени               │    Interest from penalties                                         │
│    │                                                       │                                                                    │
│12  │      Лицензионные платежи (роялти)                    │    Royalties                                                       │
│    │                                                       │                                                                    │
│13  │      Доходы от аренды (лизинга) движимого             │    Income from  leasings of movable                                │ 

│    │      имущества                                        │    property                                                        │
│    │                                                       │                                                                    │
│14  │      Доходы от аренды (лизинга) недвижимого имущества │    Income from leasings of real estate                             │
│    │                                                       │                                                                    │
│15  │      Премии по прямому страхованию и сострахованию    │    Premiums from  direct insurance and                             │
│    │                                                       │    coinsurance                                                     │
│    │                                                       │                                                                    │
│16  │      Премии по перестрахованию                        │    Premiums from reinsurance                                       │
│    │                                                       │                                                                    │
│17  │      Проценты на депо премий                          │    Interest on  depo of premiums                                   │
│    │                                                       │                                                                    │
│18  │      Другие доходы                                    │    Other income                                                    │
└————┴———————————————————————————————————————————————————————┴————————————————————————————————————————————————————————————————————…


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



   Налоговому агенту  For the Tax Agent _____________________________________

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

┌—————————————————————————————————————┬————————————————————————————————————————————————————————————————┬——————————————————————————‰
│ Форма 1013DT (1997)                 │                        ЗАЯВЛЕНИЕ CLAIM                         │                          │
│ Госналогслужба России               │            на предварительное освобождение от налогообложения  │         на for           │
│ Form 1013DT (1997)                  │         пассивных доходов от источников в Российской Федерации │            ┌———‰         │
│ the State Tax Service of Russia     │            for an exemption incomes sourced in Russia before   │         199│   │         │
│                                     │                      the payment is made                       │            └———…         │
│                                     │                                                                │                          │
│                                     │                                                                │                          │
├—————————————————————————————————————┼————————————————————————————————————————————————————————————————┴——————————————————————————┤
│ Место штампа "ПОЛУЧЕНО"             │  Отметка Госналогинспекции о получении Уведомления                                        │
├—————————————————————————————————————┴———————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │ 

│ 1. Иностранное лицо (Foreign entity)                                                                                            │
│                                                                                                                                 │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Полное имя   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
│                 ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                                       │
│    Name in full └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                 ┌—————————————————————————————————————————————————————————————————————————————————————————————————————————‰     │
│    Полный адрес │                                                                                                         │     │
│                 └—————————————————————————————————————————————————————————————————————————————————————————————————————————…     │
│                                                                                                                                 │
│                                                                                                                                 │
│                                             Cтрана  ┌———————————————————————————‰                       Код*          ┌———┬———‰ │
│                                                     │                           │                                     │   │   │ │
│    Full residential address                         │                           │                                     └———┴———… │
│                                             Country └———————————————————————————…                       Country code*           │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│                                                                                                                                 │
│ИНН в стране регистрации       ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰                            │
│Identification tax number      └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…                            │
│in country of registration                                                                                                       │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│2. Уполномоченный представитель, если таковой имеется                                                                            │
│   Authorized representative if any                                                                                              │
│                                              ┌—————————————————————————————————————————————————————————————————————————————‰    │
│   Полное наименование, адрес, телефон        │                                                                             │    │
│   Name, address, phone                       └—————————————————————————————————————————————————————————————————————————————…    │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│   ИНН                                        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰             │
│   Identification tax number                  └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…             │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————-———————————————————————┤
│3. Сведения об источнике дохода                                                                                                  │
│   Information about source of income                                                                        Номер**   ┌———┬———‰ │
│                   ┌———————————————————————————————————————————————————————‰                                           │   │   │ │
│Вид дохода         │                                                       │                                 Number**  └———┴———… │
│Type of income     └———————————————————————————————————————————————————————…                                                     │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Контрагент                                 Наименование        ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│Contractor                                                     └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                               ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰  │
│                                           Name in full        └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…  │
│                                                                                                                                 │
│                                                               ┌——————————————————————————————————————————————————————————————‰  │
│                                           Полный адрес        │                                                              │  │
│                                           Full address        └——————————————————————————————————————————————————————————————…  │
│                                                                                                                                 │
│                                                                                                                                 │
│                                           ИНН                         ┌——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——┬——‰      │
│                                           Identification tax number   └——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————┤
│Договор                                    Номер    ┌————————————————————————————————‰          Дата                             │
│Contract                                            │                                │                  ┌——┬——┬——┬——┬——┬——‰      │
│                                           Number   └————————————————————————————————…          Date    └——┴——┴——┴——┴——┴——…      │
├—————————————————————————————————————————————————————————————————————————————————————————————┬———————————————————————————————————┤
│                                        ┌———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬———┬————‰   │                                   │
│Сумма дохода в целых единицах***     А  └———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴———┴————…   │            Код валюты*            │
│Total income in whole                                                                        │           Currency code*          │
│currency units***                                                                            │                                   │
│                                                                                             │                                   │
├—————————————————————————————————————————————————————————————————————————————————————————————┤           ┌———┬———┬———‰           │
│Сумма налога, подлежащая                                                                     │           └———┴———┴———…           │