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    Form COD DGT 3

    Uploaded by

    hafiedzs s
    This document is an application form for claiming a tax refund of Indonesia tax withholding. It requests information such as the claimant's name and address, taxpayer ID number, country of jurisdiction, withholding tax slips, reasons for refund claim, and required documents. The claimant must declare that the information provided is true and correct.

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    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd

    Form COD DGT 3

    Uploaded by

    hafiedzs s
    311 views1 page
    This document is an application form for claiming a tax refund of Indonesia tax withholding. It requests information such as the claimant's name and address, taxpayer ID number, country of jurisdiction, withholding tax slips, reasons for refund claim, and required documents. The claimant must declare that the information provided is true and correct.

    Original Description:

    APPLICATION FORM FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM - DGT 3)

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    This document is an application form for claiming a tax refund of Indonesia tax withholding. It requests information such as the claimant's name and address, taxpayer ID number, country of jurisdiction, withholding tax slips, reasons for refund claim, and required documents. The claimant must declare that the information provided is true and correct.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    311 views1 page

    Form COD DGT 3

    Uploaded by

    hafiedzs s
    This document is an application form for claiming a tax refund of Indonesia tax withholding. It requests information such as the claimant's name and address, taxpayer ID number, country of jurisdiction, withholding tax slips, reasons for refund claim, and required documents. The claimant must declare that the information provided is true and correct.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    You are on page 1of 1

    MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA

    DIRECTORATE GENERAL OF TAXES

    APPLICATION FORM
    FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM - DGT 3)

    I the undersigned :

    Name : (1)

    Address : (2)

    Phone No. ( )
    acting as : *)
    the claimant himself - individual the claimant himself - management of non individual entity (3)

    Information of the claimant :


    Name : (4)

    Taxpayer ID No. : (5)

    Address : (6)

    Phone No. ( )
    Country/jurisdiction : (7)

    to claim refund for the following tax withheld in Indonesia : (additional paper may be used) (8)

    No. Withholding Tax Slip (No. and Date) Tax Withheld (Rupiah) Tax Refund Claimed (Rupiah)
    (A) (B) (C)
    1.
    2.
    3.
    4.
    Total
    The above tax as mentioned in column B withheld by Indonesia withholding tax agent :
    Name : (9)

    Taxpayer ID number : (10)

    Address : (11)

    Reasons of refund claim : (additional paper may be used) (12)

    Document attached : (13) *)

    Power of Attorney (completed Form - DGT 4)


    Certificate of Domicile (completed Form-DGT 5) (required only if claimant is resident of Indonesia DTC partner)

    Orignal withholding Tax slip (s) : piece(s)


    Documents to support the statement of beneficial ownership, which consists of 7 items. (required only if claiment is resident of
    Indonesian DTC partner and related article(s) in DTC mentions the beneficial owner phrase)

    Documents related to the earned income


    Statement of Claimant that the tax claimed has not been utilized to reduce the liable tax in the claimant's country/jurisdiction
    not to deduct the taxable income in the claimant's country/jurisdiction.
    Other document (s), please specify (if any) :

    Declaration :
    I declare that the information stated in this form is true, correct and complete.

    , / /
    Place and Date (mm/dd/yyyy) (14) Signature of the claimant or individual Capacity in which acting (16)
    authorized to sign for the claimant (15)
    *) Please check the appropriate box

    FORM-DGT 3

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