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 (DTC) 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.

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

Part I INCOME RECIPIENT: INDONESIA WITHHOLDING AGENT:

Tax ID Number :________________________________________________ (2)

Tax ID Number : (5)

Name :________________________________________________ (3)

Name : (6)

Address :________________________________________________ (4) Address : (7)

_________________________________________________________________________

Part II DECLARATION BY THE INCOME RECIPIENT:

I. (full name) _______________________________________________ (8) hereby declare that I have examined the information provided in this form and to the best of
my knowledge and belief it is true, correct, and complete. I further declare that |_| I am |_| this company is not an Indonesia resident taxpayer. (Please check the box
accordingly).

_________________________________(9) ___/____/___(10) ___________________(11) ___________________(12)

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

Part III 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 _____________________________(13)[name of the state]
within the meaning of the Double Taxation Convention in accordance with Double Taxation Convention concluded between Indonesia and _________________(14)
[name of the state of residence].

Date (mm/dd/yyyy): __/__/____(17)

_______________________________________ (15) Official

Stamp
Name and Signature of the Competent Authority or his (if any)
authorized representative or authorized tax office

Office address:
_______________________________________ (16) _______________________________________ (18)
Capacity/designation of signatory
_______________________________________

This form is available and may be downloaded at this website: http://www.pajak.go.id

This certificate is valid for 12 (twelve) months commencing from the date of certification.
Part IV TO BE COMPLETED IF THE INCOME RECIPIENT IS AND INDIVIDUAL
1. Name of income Recipient : __________________________________________________________________________
2. Date or birth (mm/dd/yyyy): __/__/___ (20) 3. Are you acting as an agent or a nominee?
4. Full address: ______________________________________________________________________________________
____________________________________________________________________________________________________
5. Do you have permanent home in Indonesia? □ Yes □ No *) (23)
6. In what country do you ordinarily reside? ______________________________________________________________
7. Have you ever been resided in Indonesia? □ Yes □ No *) If so, in what period? ___/___/____ to ___/___/_
Please provide the address __________________________________________________________________________
8. Do you have any office, or other place of business in Indonesia? □ Yes □ No *)
If so, please provide the address ______________________________________________________________________

Part V TO BE COMPLETED IF THE INCOME RECIPIENT IS NON INDIVIDUAL

1. Country of registration/incorporation: ___________________________________________________________________

2. Which country does the place of management or control reside? ___________________________________________
3. Addres of Head Office:_______________________________________________________________________________
_________________________________________________________________________________________________
4. Address of branches, offices, or other place of business in Indonesia (if any): ___________________________________
_________________________________________________________________________________________________

5. Nature of business (i.e. Pension Fund, Insurance, Headquarters, Financing)

6. The company is listed in stock market and the shares are regularly traded.
If yes, please provide the name of the stock market: _________________________________________ (32)
7. The creation of the entity and/or the transaction structure is not motivated by reasons to take
advantage of benefit of the DTC. (33)
8. The company has its own management to conduct the business and such management has an
independent discretion. (34)
9. The company employs sufficient qualified personnel. (35)
10. The company engages in active conduct of a trade or business (36)
11. The earned income is subject to tax in your country (37)
No more than 50 per cent of the company's income is used to satisfy claims by other persons
12.
(i.e. interest, royalties, other fees) (38)

Part VI INCOME EARNED FROM INDONESIA IN RESPECT TO WHICH RELIEF IS CLAIMED

1. Dividend, Interest, or Royalties:

a. Type of Income: _____________________________________________________________________________
b. Amount of Income liable to withholding tax under Indonesian Law: IDR _____________________________

2. Income from rendering services (including professional):

a. Type of incomes: _____________________________________________________________________________
 b. Amount of Income liable to withholding tax under Indonesian Law: IDR _____________________________
c. Period of engagement (mm/dd/yy): (43)
► From: __/__/_____ to ___/___/____ ► From: ___/___/___ to ___/___/_____
► From: __/__/_____ to ___/___/____ ► From: ___/___/___ to ___/___/_____

3. Other Type of Income:

a. Type of incomes: _____________________________________________________________________________
b. Amount of Income liable to withholding tax under Indonesian Law: IDR _____________________________

This form is available and my be downloaded at this website: http://www.pajak.go.id

*) Please check the appropriate box
I declare that I have examined the information provided in this form and to the best of my knowledge and belief it is true, co

____________________________________ ____/____/___ ___________________

Signed of the income recipient or individual Date (mm/dd/yy) Capacity in which acting
authorized to sign for the income recipient
 _______________________________________ (19)
□ Yes □ No *) (21)
_______________________________________
________________________________________ (22)

_______________________________________ (24)
? ___/___/____ to ___/___/____ (25)
________________________________________
(26)
________________________________________

_______________________________________ (27)
_______________________________________ (28)
_______________________________________ (29)
________________________________________
_______________________________________ (30)
____________________________________________

(31)
□ Yes □ No *)

________ (32)
□ Yes □ No *)
(33)
□ Yes □ No *)
(34)
(35) □ Yes □ No *)
(36) □ Yes □ No *)
(37) □ Yes □ No *)
□ Yes □ No *)
(38)

ED

_______________________________________ (39)
______________________________________ (40)

________________________________________ (41)
 ______________________________________ (42)

________________________________________ (44)
______________________________________ (45)

wledge and belief it is true, correct, and complete.

___________________
Contact Number
 INSTRUCTIONS
FOR CERTIFICATE OF DOMICILE OF NON RESIDENT
FOR INDONESIA TAX WITHHOLDING (FORM - DGT 1)

Part IV to be completed if the Income Recipient is an Individual: in relation with the income source
nominee if you are the legal own
income is generated and you are
Number 19: or assets.
Please fill in the income recipient's full name.
Number 20: Number 22:
Please fill in the income recipient's date of birth. Please fill in the income recipient
Number 21: Number 23:
Please check the appropriate box. You are acting as an agent if you act as an Please check the appropriate b
intermediary or act for and on behalf of other party Indonesia, you are considered
according to the Income Tax La
Indonesia, the Double Tax Conve
Number 24:
Please fill the name of country wh
Number 25:

Please check the appropriate b

resided in Indonesia, please fill th
where you are resided.

Number 26:

Please check the appropriate bo

other place of business in Indone
offices, or other place of business

Part V To be Completed if
Number 27:
Please fill in the country wh
incorporated.
Number 28:
Please fill in the country where t
management is situated.
Number 29:
Please fill in the address of the en
Number 30:
Please fill in the address of any b
business of the entity situated in
Number 31:
Please fill in the nature of busines
Number 32-38:
Please check the appropriate bo
facts and circumstances.

Part VI for Income Earned from

relief is claimed:
Number 39:
Please fill in type of income (e.g.
Number 40:
Please fill in the aggregate amo
tax under Indonesian Law within
Number 41:
Please fill in the type of income
professional).
Number 42:
Please fill in the aggregate amo
tax under Indonesian Law within
Number 43:
In case your income is arising fro
Number 44:
Please fill in the other type of inco
Number 45
Please fill in the amount of Incom
 RESIDENT
RM - DGT 1)

on with the income source in Indonesia. You are acting as a

e if you are the legal owner of income or of assets that the
is generated and you are not the real owner of the income
ts.

fill in the income recipient's address.

check the appropriate box. If your permanent home is in

sia, you are considered as Indonesian resident taxpayer
ng to the Income Tax Law and if you receive income from
sia, the Double Tax Conventions shall not be applied.

fill the name of country where you ordinarily reside.

check the appropriate box. In case you have ever been

in Indonesia, please fill the period of your stay and address
you are resided.

check the appropriate box. In case you have any offices, or

ace of business in Indonesia, please fill in the address of the
or other place of business in Indonesia.

To be Completed if the Income Recipient is non Individual:

fill in the country where the entity is registered or

rated.

fill in the country where the entity is controlled or where its

ement is situated.

fill in the address of the entity's Head Office.

fill in the address of any branches, offices, or other place of

s of the entity situated in Indonesia.
fill in the nature of business of the claimant.

check the appropriate box in accordance with the claimant's

nd circumstances.

for Income Earned from Indonesia in Respect to which

claimed:

fill in type of income (e.g. dividend, interest, or royalties).

fill in the aggregate amount of Income liable to withholding

er Indonesian Law within a period of month (Tax Period).

fill in the type of income from rendering services (including

ional).

fill in the aggregate amount of Income liable to withholding

er Indonesian Law within a period of month (Tax Period).

your income is arising from rendering service, please fill in the period when the service is provided.

fill in the other type of income.

fill in the amount of Income liable to withholding tax under Indonesian Law.