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Form DGT1-GHS

This document is a certificate of domicile form for non-resident taxpayers seeking relief from Indonesia tax withholding. The form requires information about the non-resident income recipient and Indonesian withholding agent. It also requires the non-resident to declare that they are a resident of a country with a double taxation agreement with Indonesia. Finally, the competent authority of the non-resident's country of residence must certify that the taxpayer is a resident according to the double taxation convention.

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1K views1 page

Form DGT1-GHS

This document is a certificate of domicile form for non-resident taxpayers seeking relief from Indonesia tax withholding. The form requires information about the non-resident income recipient and Indonesian withholding agent. It also requires the non-resident to declare that they are a resident of a country with a double taxation agreement with Indonesia. Finally, the competent authority of the non-resident's country of residence must certify that the taxpayer is a resident according to the double taxation convention.

Uploaded by

Budi Vedder
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Lampiran II

Peraturan Direktur Jenderal Pajak


MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
Nomor: PER-61/PJ/2009
DIRECTORATE GENERAL OF TAXES
Tanggal : 5 November 2009

CERTIFICATE OF DOMICILE OF NON RESIDENT


FOR INDONESIA TAX WITHHOLDING (FORM - DGT 1 )

Guidance:
This form is to be completed by a person (which includes a body of person, corporate or non corporate) :
• who is a resident of a country which has concluded a Double Taxation Convention (OTC) with Indonesia; and
• who claims relief from Indonesia Income Tax in respect of the following income earned in Indonesia (dividend, interest,
royalties, income from rendering services, and other income) subject to withholding tax in Indonesia
Do not use this form for :
• a banking institution, or
• a person who claims relief from Indonesia Income Tax in respect of income arises from the transfer of bonds or stocks
which traded or registered in Indonesia stock exchange and earned the income or settled the transaction through a
Custodian in Indonesia, other than interest and dividend.
All particulars in the form are to be properly furnished, and the form shall be signed as completed. This form must be certified
by the Competent Authority or his authorized representative or authorized tax office in the country where the income recipient
is a taxpayer resident before submitted to Indonesia withholding agent.

I NAME OF THE COUNTRY OF INCOME RECIPIENT : (1) I


INCOME RECIPIENT : INDONESIA WITHHOLDING AGENT :

Tax ID Numbe 200205664N (2) Tax ID Number 03.212.471.1 ·907.000


..................... ··················-························-···
(5)
Name Global Hospitality Solution, Pie Ltd (3) Name PT SUTERA ABADI (6)
:JCSUKMA/EllfTEe'esiiv,:i.-EDAi'AI(''' .••• •••• .. (7)
Address 841 Tamplnes St 83 #04·124 Singapore 520841 (4) Address -~-B-~-~-:.G_l~~XA~. .. ..

DECLARATION BY THE INCOME RECIPIENT :


I, (full name BemardQuekSeowYong (8) hereby declare that I have examined the
informat oni rovided in this ..form and to the ..best of my knowledge and belief it is true, correct and complete. I furt
declare that I am [K}this company is not an Indonesia resident taxpayer. (Please check the box accordingly)

(9) 05115117 (10) CEO (11) 93833731 (12)


Signature of the Income recipient or individual Date (mm/dd//yy) Capacity In which acting Contact Number
authorized to sign for the Income recipient

CERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF THE COUNTRY OF RESIDENCE :

For the purpose of tax relief , it is hereby confirmed that the taxpayer mentioned in part I is a resident in
SINGAPORE (13) (neme ot the stste) within thes?i1f~~~~t the Double Taxation Convention in accordance with Do
u
Taxation Convention concluded between Indonesia and c (14) [name of the state of residence]

Date (mm/dd/yyyy) 0 1 JUN 20l77J


Name and s,,,::~~~~tt
his authorized
--s. ~tive
the Competent '""""':•:
or authorized tax office 55 Newton Road
Ms Lee Imm
Tax Director
Office address Revenue House
Corporate Tax Division (16) Singapore 307987 09J
Capacity/designation of signatory

ttus form is avatlable and may be downloaded at tht» website. http://www.paiak.go.id

This certificate is valid for 12 (twelve) months commencing from the date of certification

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