2024年1月21日发(作者：)

附件 4

Annex 4

非居民享受税收协定待遇身份信息报告表（适用于个人）

Personal information of non-residents claiming for treatment under

Double Taxation Agreement(DTA) (for individuals)

填报日期Date 年 月 日Y/M/D

纳税人基本情况

Taxpayer's information

1在缔约对方姓名

Name in the

other

contracting party

2中文姓名

Name in

Chinese

3在缔约对方纳税识别号

Tax indentification number in the other

contracting party

4

家庭成员姓名

Name of family

member

5

与纳税人关系

relationship with

the taxpayer

6

经常居住地

habitual residence

7

备注

Additional information

构成缔约对方税收居民情况:

Qualification as a fiscal resident of the other contracting party

8构成缔约对方税收居民的法律依据描述:

Legal provisions prescribing the status of the taxpayer as a fiscal resident of the other

contracting party

9构成缔约对方税收居民的事实情况描述:

Description of facts based on which the taxpayer qualifies as a fiscal resident of the other

contracting party

10在缔约对方是否保有长期居所

Does the taxpayer have permanent residence in the other contracting party?

□是 Yes □否 No

11在缔约对方是否取得长期居留权

Does the taxpayer have the right to permanently stay in the other contracting party?

□是 Yes □否 No

12在缔约对方保有的投资额

Amount of investment kept in the other contracting party

13最近连续12个月内在缔约对方连续或累计停留天数

Number of days of continuous stay or cumulative stays in the other

contracting party in the past 12 months

14是否保有缔约对方国籍

Does the taxpayer hold nationality of the other contracting party?

□是 Yes □否 No

从中国取得所得在缔约对方纳税情况(限于列入税收协定适用范围的税种):

Information of tax payment in the other contractiong party on the income derived from China

(taxes covered by DTA only)

16

适用税率或税率表

Effective tax

rate(s)

17

享受缔约对方国内减免税优惠的法律依据

及条文描述

Legal provisions prescribing tax deduction or exemption

enjoyed in the other contracting party

15

税种名称

Type of tax

是否构成第三方税收居民

Whether a fiscal resident of a jurisdiction other than China & the other contracting party

18是否在第三方负有居民纳税义务

Is the taxpayer liable to tax for his worldwide income in a

jurisdiction other than China & the other contracting party?

□是 Yes □否 No

19是否在第三方保有长期居所

Does the taxpayer have perment residence in a jurisdiction

other than China & the other contracting party?

□是 Yes □否 No

20是否在第三方取得长期居留权

Does the taxpayer have the right to permenantly stay in a

jurisdiction other than China & the other contracting party?

□是 Yes□否 No

21是否在第三方保有的投资额超过

缔约对方投资额

Does the amount of investment in a jurisdiction other than

China & the other contracting party exceed that in the other

contracting party?

□是 Yes □否 No

22最近连续12个月内是否在第三方连续或累计超过180天

Does the taxpayer stay in a jurisdiction other than China &

the other contracting party for a period or periods exceeding

in the aggregate 180 days in the past 12 months?

□是 Yes □否 No

23是否保有第三方国籍

Does the taxpayer hold the nationality of a jurisdiction other

than China & the other contracting party?

□是 Yes □否 No

是否构成中国税收居民

Whether a fiscal resident of China

第三方名称

Name of the

jurisdiction

第三方名称

Name of the

jurisdiction

第三方名称

Name of the

jurisdiction

第三方名称

Name of the

jurisdiction

第三方名称

Name of the

jurisdiction

第三方名称

Name of the

jurisdiction

24在中国境内是否有住所

Does the taxpayer have domicile in China?

□是 Yes □否 No

25在中国境内是否保有长期居所

Does the taxpayer have permanent residence in China?

□是 Yes □否 No

26是否取得在中国的长期居留权

Does the taxpayer have the right to permanently stay in China?

□是 Yes □否 No

27在最近纳税年度内在中国连续或累计停留天数

Number of days of continuous stay or cumulative stays in China in the

past taxable year

28在中国保有的投资额

Amount of investment in China

29是否具有中国国籍

Does the taxpayer hold the nationality of China?

□是 Yes □否 No

填表说明：

Note

1本表为《非居民享受税收协定待遇审批申请表》附表，适用于在《非居民享受税收协定待遇申请表》第3栏中选择为个人的纳税人。

This form is attached to the form "Non-resident's claim for treatment under Double Taxation

Agreement(DTA) (for apprroval)". Applicable when "individual taxpayer" is selected in Blank 3

in that form.

2本表第4栏中家庭成员包括配偶、未成年子女以及共同生活的其他抚养或赡养人员。

"Family member" in Blank 4 includes spouse, dependant children, and other dependent family

members living together.

3本表第6栏中经常居住地是指除仅满足工作、学习需要的临时居住地以外的日常生活居住地。各家庭成员经常居住地不同的，应在备注栏中说明原因 。

"Habitual residence" in Blank 6 refers to the residence for daily life, other than temporary stay

for work or study. If family members have different habitual residence, please specify the

reasons in "Additional information".

4本表有关栏中长期居所包括拥有或承租的可供居住五年以上的任何居住场所。

"Permanent residence" in this form includes any residential location owned or rented by the

taxpayer available to live for more than 5 years.

5本表有关栏中投资仅指对不动产、经营性资产和有价证券的投资。有价证券投资按有价证券发行者所在地确定投资地。

"Investment" only refers to real property, operating assets and securities. Location of security

investment is determined by the location of securities' issuer.

6本表有关栏中长期居留权是指居住达五年以上的居留权。

"The right to pemanently stay" refers to a right to stay for more than 5 years.

7本表第24栏中住所按《中华人民共和国个人所得税法》及其实施条例和有关税收规定确定。

"Domicile" in Blank 24 is determined by the Individual Income Tax Law of the People's

Republic of China, Regulations for the Implementation of the Individual Income Tax law and

other related provisions.