KEMENTERIAN KEUANGAN REPUBLIK INDONESIA DIREKTORAT JENDERAL PAJAK PERATURAN DIREKTUR JENDERAL PAJAK NOMOR PER- 40 /Pu/2010 TENTANG PENGEMBALIAN KELEBIHAN PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK TERUTANG Menimbang Mengingat Menetapkan BAGI WAJIB PAJAK LUAR NEGERI DIREKTUR JENDERAL PAJAK, a. bahwa berdasarkan ketentuan Pasal 32A Undang-Undang Nomor 7 Tahun 1983, tentang Pajak Penghasilan sebagaimana telah beberapa kali diubah terakhir dengan Undang-Undang Nomor 36 Tahun 2008 diatur bahwa pemerintah berwenang untuk melakukan perjanjian dengan pemerintah negara lain dalam rangka penghindaran pajak berganda dan pencegahan pengelakan pajak; b. bahwa dalam rangka melaksanakan ketentuan Pasal 9 Peraturan Menteri Keuangan Nomor 190/PMK.03/2007 tentang Tata Cara Pengembalian Kelebinan Pembayaran Pajak Yang Seharusnya Tidak Terutang, c. bahwa berdasarkan pertimbangan sebagaimana dimaksud dalam huruf a dan hurut b, perlu menetapkan Peraturan Direktur Jenderal Pajak tentang Pengembalian Kelebihan Pembayaran Pajak Yang Seharusnya Tidak Bagi Wajib Pajak Luar Negeri; 4. Undang-Undang Nomor 6 Tahun 1983 tentang Ketentuan Umum dan Tata Cara Perpajakan (Lembaran Negara Republik Indonesia Tahun 1983 Nomor 49, ‘Tambahan Lembaran Negara Republik Indonesia Nomor 3262) sebagaimana telah beberapa kali diubah terakhir dengan Undang-Undang Nomor 16 Tahun 2009 (Lembaran Negara Republik Indonesia Tahun 2009 Nomor 62, Tambahan Lembaran Negara Repulbik Indonesia Nomor 4999); 2. Undang-Undang Nomor 7 Tahun 1983 tentang Pajak Penghasilan (Lembaran Negara Republik Indonesia Tahun 1983 Nomor 50, Tambahan Lembaran Negara Republik Indonesia Nomor 3263) sebagaimana telah beberapa kali diubah terakhir dengan Undang-Undang Nomor 36 Tahun 2008 (Lembaran Negara Republik Indonesia Tahun 2008 Nomor 133, Tambahan Lembaran Negara Republik Indonesia Nomor 4893); 3. Peraturan Menteri Keuangan Nomor 188/PMK.03/2007 tentang Tata Cara Pengembalian Kelebihan Pembayaran Pajak; 4, Peraturan Menteri Keuangan Nomor 190/PMK.03/2007 tentang Tata Cara Pengembalian Kelebihan Pembayaran Pajak Yang Seharusnya Tidak Terutang; MEMUTUSKAN: PERATURAN DIREKTUR JENDERAL PAJAK TENTANG PENGEMBALIAN KELEBIHAN PEMBAYARAN PAJAK YANG SEHARUSNYA TIDAK TERUTANG BAGIPasal 1 Dalam Peraturan Direktur Jenderal Pajak ini yang dimaksud dengan: 1. Persetujuan Penghindaran Pajak Berganda yang selanjutnya disebut P&B adalah perjanjian antara Pemerintah Indonesia dengan pemerintah negara/jurisdiksi tain dalam rangka penghindaran pajak berganda dan pencegahan pengelakan pajak. 2. Wajib Pajak luar negeri selanjutnya disebut WPLN adalah subjek pajak luar negeri sebagaimana dimaksud dalam Undang-Undang Nomor 7 Tahun 1983 tentang Pajak Penghasilan sebagaimana telah beberapa Kali diubah terakhir dengan Undang- Undang Nomor 36 Tahun 2008. 3. Pemotong/Pemungut Pajak adalah badan pemerintah, subjek pajak dalam negeri, penyelenggara kegiatan, bentuk usaha tetap, atau perwakilan perusahaan lar negeri lainnya yang diwajibkan untuk melakukan pemotongan atau pemungutan pajak atas penghasilan yang diterima atau diperolen WPLN sesuai ketentuan yang berlaku, termasuk P3B. 4, Pajak Yang Seharusnya Tidak Terutang adalah pajak atas penghasilan yang diterima atau diperoleh WPLN yang seharusnya tidak dipotong atau dipungut oleh Pemotong/Pemungut Pajak sesuai dengan ketentuan yang berlaku, termasuk PSB. 5. Pejabat Yang Berwenang adalah pejabat yang berwenang sebagaimana dimaksud dalam P3B. 6. Prosedur Persetujuan Bersama atau Mutual Agreement Procedures selanjutnya disebut MAP adalah prosedur yang dijalankan oleh Pejabat Yang Berwenang akibat penerapan P3B yang tidak sebagaimana mestinya sesuai dengan ketentuan yang diatur dalam P3B. 7. Kesepakatan Dalam Rangka MAP (mutual agreement) adalah kesepakatan antara Pejabat Yang Berwenang dari indonesia dan Pejabat Yang Berwenang dari negara mitra P3B dalam rangka menjalankan MAP sesuai dengan ketentuan yang diatur dalam P3B. 8. Surat Keterangan Domisili yang selanjutnya disebut SKD adalah formulir Certificate of Domicile of Non Resident for Claiming Tax Refund of Indonesia Tax Withholding (Form-DGT 5) yang diisi oleh WPLN. 9. Kantor Pelayanan Pajak yang selanjutnya disebut KPP adalah Kantor Pelayanan Pajak tempat Pemotong/Pemungut Pajak terdaftar sebagai Wajib Pajak Pemotong/Pemungut Pajak. 10. Surat Pemberitahuan Masa yang selanjutnya disebut SPT Masa adalah Surat Pemberitahuan yang digunakan oleh Pemotong/Pemungut Pajak untuk melaporkan penghitungan dan penyetoran atas pemotongan atau pemungutan pajak yang telah dilakukan untuk suatu Masa Pajak tertentu sesuai dengan ketentuan yang berlaku. Pasal 2 Pajak Yang Seharusnya Tidak Terutang atas penghasilan yang diterima atau diperoleh WPLN meliputi a. kesalahan pemotongan atau pemungutan pajak yang mengakibatkan pajak yang dipotong atau dipungut oleh Pemotong/Pemungut Pajak lebih besar daripada pajak yang seharusnya dipotong atau dipungut berdasarkan ketentuan yang berlaku, termasuk P3B; b. pemotongan atau pemungutan pajak atas penghasilan yang bukan objek pajak; atau ota, namin tan nein vane Iahih heear darinada vana eeharienva:Rangka MAP. Pasal3 (1) Wajb Pajak yang dapat mengajukan permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang sebagaimana dimaksud dalam Pasal 2 adalah WPLN yang tidak menjalankan kegiatan atau usaha melalui bentuk usaha tetap di Indonesia (2) Permohonan sebagaimana dimaksud pada ayat (1) harus diajukan oleh WPLN melalui Pemotong/Pemungut Pajak. Pasal 4 (1) Permohonan sebagaimana dimaksud dalam Pasal 3 ayat (1) haus memenuhi persyaratan sebagai berikut: ‘a. diajukan secara tertulis kepada Direktur Jenderal Pajak melalui Kepala KPP dengan menggunakan Form-OGT 3 sebagaimana ditetapkan dalam Lampiran | Peraturan Direktur Jenderal Pajak ini; b. Form-DGT 3 sebagaimana dimaksud pada huruf a harus: 1) diisi dengan benar, lengkap, dan jelas; 2). diisi dalam bahasa Ingatis; 3) ditandatangani oleh WPLN; 4) mencantumkan alasan permohonan WPLN secara jelas; dan 5) mencantumkan jumlah pajak yang diminta untuk dikembalikan; . dilampiti dengan surat kuasa, dan d._dilengkapi dengan dokumen pendukung. (2) Permohonan yang tidak memenuhi persyaratan sebagaimana dimaksud pada ayat (1) dianggap bukan surat permohonan pengembalian kelebihan pembayaran Pajak Yang Tidak Seharusnya Terutang, sehingga tidak dipertimbangkan. Pasal 5 Pemotong/Pemungut Pajak harus menyampaikan permohonan WPLN yang telah memenuhi persyaratan sebagaimana dimaksud dalam Pasal 4 kepada Kepala KP. Pasal 6 Surat kuasa sebagaimana dimaksud pada Pasal 4 ayat (1) huruf ¢ harus dibuat oleh WPLN dengan memenuhi syarat-syarat sebagai berikut: ‘a. menggunakan Form-DGT 4 sebagaimana ditetapkan dalam Lampiran Il Peraturan Direktur Jenderal Pajak; b. Form-DGT 4 sebagaimana dimaksud pada huruf a harus: 1) dilsi dengan benar, lengkap, dan jelas; 2) diisi dalam bahasa Inggris;5) perundang-undangan perpajakan yang berlaku, mencantumkan pernyataan pemberian kuasa kepada Pemotong/Pemungut Pajak untuk menyampaikan permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang beserta kelengkapannya ke KPP dan bertindak mewakili WPLN untuk menerima pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang, Pasal7 (1) Dokumen pendukung sebagaimana dimaksud dalam Pasal 4 ayat (1) huruf d terdiri dari: a SKD dengan menggunakan Form-DGT 5 sebagaimana ditetapkan dalam Lampiran Il Peraturan Direktur Jenderal Pajak ini; bukti pemotongan/pemungutan pajak asli yang dimintakan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang; ‘surat pernyataan WPLN bahwa pajak yang dimintakan pengembalian belum diperhitungkan dengan pajak WPLN yang terutang di luar negeri dan/atau belum dibebankan sebagai biaya dalam penghitungan penghasilan kena pajak WPLN diluar negeri; dalam hal WPLN adalah subjek pajak dalam negeri dari negara/jurisdiksi mitra PSB Indone: dalam P38 memuat klausul beneficial owner, yaitu dan menerima atau memperoleh penghasilan yang pasal terkait 1) nama, alamat, kewarganegaraan, dan informasi rinci mengenai dewan direksi; 2) identitas dan informasi rinci mengenai pemegang saham; 3) jumlah pegawai dan informasi rinci mengenai tugasnya; 4) penjelasan atas investasi yang menimbulkan penghasilan; 5) sumber pendanaan investasi; 6) penggunaan atau rencana penggunaan penghasilan yang bersumber dari Indonesia; dan 7) laporan keuangan dan surat pemberitahuan pajak untuk tahun yang mencakup saat terjadinya transaksi dan 2 (dua) tahun sebelumnya; dokumen yang berkaitan dengan jenis penghasilan: 1) bunga: a) perjanjian pemberian atau penyediaan pinjaman/utang; b) jurnal pencatatan penerimaan bunga, ©) _rekening bank penerimaan dan penggunaan penghasilan, dan d) notice of interest computation; 2) dividen: 1) dividend declaration dari perusahaan yang membayar dividen; b)_ rekening bank penerimaan dan penggunaan penghasilan, dan ©) surat keterangan dari pembayar dividen yang menyatakan bahwa pemohon adalah pemegang saham yang berhak menerima dividen; 3) royalti, sewa, dan penghasilan lain dari penggunaan harta:b) jurnal pencatatan penerimaan penghasilan, ©) rekening bank penerimaan dan penggunaan penghasilan, dan 4) notice of income computation; 4) imbalan jasa, balk yang dilakukan oleh individu maupun badan: )_perjanjian pemberian/penyediaan jasa; b)_pernyataan WPLN bahwa WPLN tidak menjalankan kegiatan atau usaha di Indonesia melalui suatu bentuk usaha tetap; dan ©) surat keterangan dari Pemotong/Pemungut Pajak mengenai lamanya pelaksanaan pemberian/penyediaan jasa di Indonesi 5) penghasitan dari penjualan atau pengalihan saham perusahaan di Indonesia: a) perjanjian penjualan atau pengalihan saham; dan b) akta pemindahan hak atas saham yang dijual atau dialinkan dari perusahaan di indonesia yang sahamnya dijual atau dialihkan; 6) _premi asuransi dan premi reasuransi: a) polis asuransi/reasuransi; dan b) notice of premium computation; 7)_ branch profit bentuk usaha tetap: a) Surat Pemberitahuan Tahunan Pajak Penghasilan bentuk usaha tetap; dan b) surat keterangan Wajib Pajak bentuk usaha tetap yang menerangkan alasan pemotongan pajak atas branch profit; 8) penghasilan lainnya’ a) pemyataan Pemotong/Pemungut Pajak bahwa WPLN adalah pemilik sah atas penghasilan; dan b) _penjelasan WPLN mengenai substansi penghasilan; dan . dokumen lain yang menurut WPLN atau Pemotong/Pemungut Pajak perlu disampaikan kepada Direktur Jenderal Pajak. (2) Form-DGT 5 sebagaimana dimaksud pada ayat (1) huruf a hanya dipersyaratkan bagi WPLN yang merupakan subjek pajak dalam negeri di negara/jurisdiksi mitra P3B dan harus memenuhi persyaratan sebagai berikut: ‘a. diisi oleh WPLN dengan benar, lengkap, dan jelas; b. ditandatangani olen WPLN atau diberi tanda yang setara dengan tanda tangan sesuai dengan kelaziman di negaral/jurisdiksi mitra P3B; ¢. telah disahkan oleh Pejabat Yang Berwenang, wakiinya yang sah, atau pejabat kantor pajak yang berweneng di negara/jurisdiksi mitra P3B, yang dapat berupa tanda tangan atau diberi tanda yang setara dengan tanda tangan sesuai dengan kelaziman di negara/jurisdiksi mitra P38; dan d. dalam hal WPLN tidak dapat memperoleh pengesahan Pejabat Yang Berwenang di negarajurisdiksi mitra P3B pada Form-DGT-5 sebagaimana dimaksud pada huruf c, pengesahan dimaksud dapat digantikan dengan surat keterangan domisili asi yang lazim disahkan atau diterbitkan oleh negara/jurisdiksi mitra P3B dengan memenuhi persyaratan sebagai berikut: 1) menggunakan bahasa Ingaris; 2) sekurang-kurangnya mencantumkan informasi mengenai nama WPLN;4) mencantumkan tanda tangan Pejabat Yang Berwenang, wakilnya yang sah, atau pejabat kantor pajak yang berwenang di negara mitra P3B atau tanda yang setara dengan tanda tangan sesuai dengan kelaziman di negara/jurisdiksi mitra P38 dan nama pejabat dimaksud. (8) Dalam hal permohonan WPLN terkait dengan pelaksanaan Kesepakatan Dalam Rangka MAP sebagaimana dimaksud dalam Pasal 2 huruf c, dokumen pendukung sebagaimana dimaksud dalam Pasal 4 ayat (1) huruf d terdiri dari: a. bukti pemotongan/pemungutan pajak asli yang dimintakan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang; dan b. fotokopi surat Kesepakatan Dalam Rangka MAP. Pasal 8 Dalam rangka menyeleseikan permohonan WPLN, Kepala KPP: irektur Jenderal Pajak melalui a. melakukan penelitian atas permohonan pengembalian kelebinan pembayaran Pajak Yang Seharusnya Tidak Terutang; b. dapat meminta keterangan dari Pemotong/Pemungut Palak, WPLN, Pejabat Yang Berwenang di negara mitra P3B, dan/atau pihak lain. Pasal 9 (1) Permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang ditolak dalam hal berdasarkan hasil penelitian sebagaimana dimaksud dalam Pasal 8 huruf a a. WPLN merupakan subjek pajak dalam negeri Indonesia; b. pajak yang dipotong atau dipungut belum disetor oleh Pemotong/Pemungut Pajak; ©. pajak yang dipotong atau dipungut telah: 1) diperhitungkan dengan pajak WPLN yang terutang di luar negeri, 2) telah dibebankan sebagai biaya dalam penghitungan penghasilan kena pajak WPLN di luar negeri, atau 3) ditanggung oleh atau menjadi beban Pemotong/Pemungut Pajak; d._ petmohonan WPLN tidak sesuai dengan ruang lingkup P3B; . terjadi penyalahgunaan P3B sebagaimana dimaksud dalam ketentuan mengenai pencegahan penyalahgunaan P3B; atau pajak yang dipotong atau dipungut oleh Pemotong/Pemungut Pajak telah sesuai dengan ketentuan yang berlaku, termasuk PSB. (2) Permohonan pengembalian kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang terkait dengan pelaksanaan Kesepakatan Dalam Rangka MAP sebagaimana dimaksud dalam Pasal 2 huruf c ditolak dalam hal berdasarkan penelitian sebagaimana dimaksud dalam Pasal 8 huruf a: ‘a. pajak yang dipotong atau dipungut belum disetor oleh Pemotong/Pemungut Pajak; atau b. jumlah kelebihan pembayaran Pajak Yang Seharusnya Tidak Terutang menurut permohonan WPLN lebih besar daripada jumlah kelebihan pembayaran Pajak(3) Permohonan WPLN yang bukan berasal dari negara/jurisdiksi mitra P3B Indonesia ditolak dalam hal berdasarkan hasil penelitian sebagaimana dimaksud dalam Pasal 8 huruf a: a. WPLN merupakan subjek pajak dalam negeri Indonesia; b. pajak yang dipotong atau dipungut belum disetor oleh Pemotong/Pemungut Pajak, ©. pajak yang dipotong atau dipungut telah: 1) diperhitungkan dengan pajak WPLN yang terutang di luar negeri, 2) dibebankan sebagai biaya dalam penghitungan penghasilan kena pajak WPLN di luar negeri, atau 3) ditanggung oleh atau menjadi beban Pemotong/Pemungut Pajak; atau ._pajak yang dipotong atau dipungut telah sesuai dengan ketentuan yang berlaku. (4) Dalam hal terdapat pajak yang dipotong atau dipungut, namun belum disetor oleh Pemotong/Pemungut Pajak, Kepala KPP menagih pajak yang terutang kepada Pemotong/Pemungut Pajak sesuai Ketentuan yang berlaku, (6) Dalam hal SPT Masa belum dilaporkan oleh Pemotong/Pemungut Pajak, Kepala KPP harus menindaklanjutinya sesuai ketentuan yang berlaku Pasal 10 (1) Setelah melakukan penelitian sebagaimana dimaksud dalam Pasal 8 huruf a, Kepala KPP atas nama Direktur Jonderal Pajak menerbitkan Surat Ketetapan Pajak Lebih Bayar atas nama Pemotong/Pemungut Pajak q.q. WPLN, apabila terdapat Pajak Yang Seharusnya Tidak Terutang, paling lama 3 (tiga) bulan sejak permohonan ‘WPLN diterima secara lengkap. (2) Dalam hal permohonan WPLN ditolak, Direktur Jenderal Pajak melalui Kepala KPP harus memberitahukan secara tertulis kepada WPLN melalui Pemotong/Pemungut Pajak paling lama 3 (tiga) bulan sejak permohonan WPLN diterima secara lengkap dan dengan menyebutkan alasan penolakannya. (8) Berdasarkan Surat Ketetapan Pajak Lebih Bayar sebagaimana dimaksud pada ayat (1), Kepala KPP atas nama Direktur Jenderal Pajak menerbitkan Surat Keputusan Pengembalian Kelebihan Pembayaran Pajak atas nama Pemotong/Pemungut Pajak 4.9. WPLN sesuai dengan ketentuan yang berlaku. (4) Atas dasar Surat Keputusan Pengembalian Kelebihan Pembayaran Pajak sebagaimana dimaksud pada ayat (3), Kepala KPP atas nama Menteri Keuangan menerbitkan Surat Perintah Membayar Kelebihan Pembayaran Pajak atas nama Pemotong/Pemungut Pajak q.q. WPLN sesuai dengan ketentuan yang berlaku dengan mencantumkan nomor rekening bank yang berada di Indonesia milik Pemotong/Pemungut Pajak dan dengan menggunakan mata ang Rupiah. Pasal 11 Pada saat berlakunya Peraturan Direktur Jenderal Pajak ini, Surat Edaran Direktur Jenderal Pajak Nomor SE-09/PJ.10/1994 tentang Restitusi Pajak Penghasilan Pasal 26 ‘Sehubungan Dengan Ketentuan Dalam PPPB dinyatakan tidak berlaku, kecuali untuk permohonan pengembalian Pajak Penghasilan Pasal 26 dalam rangka penerapan ketentuan P3B yang telah diajukan oleh WPLN sebelum berlakunya Peraturan Direktur Jenderal Pajak ini.Pasal 11 Peraturan Direktur Jenderal Pajak ini mulai berlaku pada tanggal ditetapkan. Ditetapkan di Jakarta pada tanggal 9 Agustus 2010 AD TJIPTARDJO 4281975121002MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA roman stan SPS DIRECTORATE GENERAL OF TAXES vena aaa APPLICATION FORM FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 3) | the undersigned: Name oe) Address —_ __ ® Phone No. acting as: the claimant himsettindividval C1 the claimant himself-management of non individual entty —_@) Information ofthe claimant: Name ____ w Taxpayer ID No © Address (6) _ Phone No). Country/jurisdiction nn to-claim refund forthe following tax withheld in Indonesia: (aston apr ay buss) (8) No. ‘Withholding Tax Slip (No. and Date) "Fax Withheld (Rupiah) x Refund Claimed (Rupiah) we @) so a Total The above tax as mentioned in column B withheld by Indonesia withholding tax agent: Name 7 e ‘Taxpayer ID number Address Reasons of refund claim: ictarapapernyte sed) (12) Documents attached: (19) ” 1 Power of Attorney (completed Form-DGT 4) 1 Cottificate of Domicile (completed Form-DGT 5) mourn ony aman reton ot ndsasan OFC gan) Original withholding tax slip(s) piece(s) 1 Documents to suppor the statement of beneficial ownership, which consists of 7 items. ogi ony lian ein of Insonen OTC pune neta) DTC mere heb one a0) 1 Documents related to the earned income 1 Statement of Claimant that the tax claimed has not been utlized to reduce the liable tax in the claimant's ‘country/jurisdiction nor to deduct the taxable income in the claimant's country/jurisdiction, 1 Other document(s), please specify «am Declaratior | declare that the information stated in this form is true, correct and complete. sd. Place and Date (mmiddiyyyy) (14) ‘Capacity in which acting (16)INSTRUCTIONS, FOR APPLICATION FORM FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 3) General Information: 1. Non resident who has been withheld income tax by Indonesia withholding tax agent may claim tax refund to the Director General of Taxes, in case: ‘a. the non resident considers that the tax withheld is not, in accordance with Indonesian incame tax law and/or Double Taxation Convention/Agreement (OTC) concluded by Indonesia and his domicile country/ jurisdiction, oF b. the non resident claims tax refund as the agreed result of Mutual Agreement Procedures conducted by the Competent Authorities of Indonesia and of treaty partner. 2. The application must be made by non resident taxpayer who claims the refund (‘the Claimant’) and must be ‘submitted through the Indonesia withholding tax agent. 3. One application must be made for any tax claims related t0.cne withholding tax agent. 4, The Claimant must grant a specific power of attomey to the withholding tax agent to lodge the application to the Director General of Taxes and to provide a bank account which will be used to transfer the approved tax refund. 5. Documents and information that are required to be provided by the Claimant (please read the related instructions for details) ‘a. The application (completed Form-DGT 3), b. The power of attorney (completed Form-DGT 4), ©. The certificate of domicile (completed Form-DGT 5)- which is only required only if the Claimant is resident of the Indonesia DTC partner), 4d, The withholding tax slips (original), fe, The Claimant statement that the tax claimed has not been utlized to reduce the liable tax nor to deduct the taxable income in calculating the lable tax in the claimant's country/jurisdiction, 1. Specific documents related to the earned income, 9. Specific documents/information to support the beneficial ownership statement, which is only required if the Claimant is resident of indonesia DTC partner and the related article(s) in DTC mentions the beneficial owner phrase. 6. Director General of Taxes shall give a decision not more than 3 (three) months since the application is lodged ‘completely. Should the application is refused; a writen notification will be sent to the Claimant through the withholding tax agent 7. An Overpayment Tax Assessment Letter (SKPLB) will be Issued for approved claim to process the refund transfer to the withholding tax agent's bank account. For transferring any tax refund, it is required a bank account, Rupiah currency, in any bank that is situated in Indonesia. Guidance to fill the application: Form-DGT 3 is downloadable at hitpijwerw.palak. oo. Number 1 Please fil n the name of individual who signs this form. For individual, please fil in the name of the Claimant. For non Individual entity, please fil in the name of individual who may act as the representative of the Claimant. Number 2: Number 4 to 6: This section must be filed with information of the Claimant whose income is withheld by Indonesia withholding tax agent. (4) Please fil in the Claimant's name. (6) Please fil in the Claimant's taxpayer identification number in. country/juisdiction where the claimant registered as a taxpayer resident (6) Please fil in the Claimant's address. (7) Please fill in the countryjurisdiction where the claimant registered as a taxpayer resident. Number 8: Please fill in the column (A) with the number and date of withholding tax slip(s) issued by withholding tax agent, column (@) with the amount of tax withheld as stated in the withholding tax slip (in Rupiah) and column (C) with the amount of tax claimed (in Rupiah. Please total the amount of column (8) and (C) respectively ‘Additional paper may be used, Number 9-11: This section requires the claimant to fil in the information regarding Indonesia withholding tax agent. You may refer to information provided in withholding tax slips. (@) Please fil in the name of the withholding tax agent. (10) Please fil n the taxpayer identification number (NPWP) of the withholding tax agent (11) Please fil in the address of the withholding tax agent. Number 12: Please provide reasons to claim the tax withheld and any articles of the Double Tax Convention (DTC) which relevant or related to the claim, The Claimant may state his reasons and arguments to suppor that the tax withheld is notin accordance with the Indonesian income tax law and/or the DTC. Additional paper may be used by the claimant Number 13: Please check the appropriate box to declare that the Claimant has completed all the requirements. Notes: The failure to present the following attachment will ‘cause the Director General of Taxes to refuse the application. a. Power of Attorney (completed Form-DGT 4). The form Js downloadable at hitp/iwi.pajak.go.id. The Claimant ‘must provide a specific power of altomey to grant power to the withholding tax agent to submit the application and to provide a bank account number. This document is liable to Indonesian stamp duty (IDR 6,000) according to the Law No.13 Year 1985, b. Certificate of Domicile (completed Form-DGT 5). The form is downloadable at hitp:/Avww.palak.go.id. This form Is required to be submitted for the application of the DTC. The form of conificate of domicile, issued by the Directorate General of Taxes and’ must be filed completely and signed by the Claimant. The first page of this certificate must be authorized by the Competent Authorities, his representative or authorized tax office in Ccountryjurisdiction where the Claimant is registered as a taxpayer resident. In case the competent authority, his authorized representative, or the authorized tax office ‘cannot put his authorization in this form, the Claimant may submit the certificate of domicile, as an altachment of Form-DGT 5, which is usually issued in the Claimant's ‘country/urisdiction and such certificate shall meet the requirements as provided in the instruction of Form-DGT 6.INSTRUCTIONS FOR APPLICATION FORM FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 3) ‘The Claimant statement that the tax claimed has not been utlized to reduce the liable tax nor to deduct the taxable income in calculating the liable tax in the Claimant's ‘country/urisdiction. Document(s) related to the 1) Interest income: a) the loan agreement, ned income. bb) the recording journal ofthe receipt of income, ©) the bank statement that showing the receipt and the use of income, and 4) a notice of interest computation; 2) Dividend income: a) a doclaration of dividend distribution issued by the Indonesian entity who paid the dividend, b) the bank statement that showing the receipt and the use of income, and ©) @ statement letter made by the company who distributed the dividend mentioning that the Claimant is the rightful owner of dividend, 3) Royalties, rent_and ot th use of oF for the right to use asset, property or ‘equipment; a) the related agreement, ) the recording journal ofthe receipt of income, ©) the bank statement that showing the receipt and the use of income, and d)__anotice of income computation; 4) Income from services, rendered by individual or hon individual: a) the related service agreement; ») a statement letter made by the claimant mentioning that claimant conducted business or Activites in Indonesia not through a permanent establishment, ) a statement letter issued by the Indonesian vuthhnolding” tax-agent mentioning that the claimant rendered services in Indonesia for a period not mare than the period stipulated in the DTC to constitute a permanent establishment, 5) Gains from the alienation of shares: '8)_ the agreement related tothe alienation of shares of a company situated in Indonesia, b) Notary deed on transfer of right of the alienated shares. 6) Insurance or reinsurance premium: a) the insurance policy, and b) notice of premium computation; 7) branch profit of a permanent establishment a) the insurance policy, b) the annual income tax return of the related permanent establishment that situated in Indonesia, ©) @ satement letter issued by the permanent establishment who acts as the withnolding tax agent concerning the ground of the tax withholding 8) Other income: a) @ statement letter issued by the Indonesian withholding tax agent mentioning that the Claimants the rightful owner ofthe income; the claimant regardin the 9 These documents are required to be submitted by the claimant who is a resident in country/urisdiction that has concluded DTC with indonesia and the related article in DTC mentions the beneficial owner phrase. ‘To support that the Claimant is the beneficial owner of the Income, the following information (7 items) must be provided as attachment of the application (completed Form-DGT 3}: 1) Name, address, nationality and other detailed Information of board of directors; 2) Name, address, shares and other information concerning the shareholders; 3) Number of employees and detalled job description 4) Description of investment which generates. the income related to the tax claimed: 5) Financial sources of the investment; 6) The use or the plan of use of income generated by the investment; 7) The Claimant's financial statements and reported income tax return for year when the payment ‘occured and for the 2 (two) years before. Other documents detailed The Claimant or the withholding tax agent may attach documents other than the required documents mentioned above to support the claim, Notes: a In case the tax claimed by the Claimant is resulted from ‘mutual agreement agreed by both Competent Authorities through a Mutual Agreement Procedures, the claimant is, only required to submit the following documents: 41) Power of Attorney (completed Form-DGT 4), 2) Original withholding tax slips), and 3) Copy of mutual agreement. This document is produced by both Competent Authorities. in ‘conducting the Mutual Agreement Procedures b. In case the Claimant is not a resident taxpayer of a ccountryjurisdiction which has concluded DTC with Indonesia, the Claimant is only required to submit the following documents: 1) Power of Attorney (completed Form-DGT 4), 2). Original withholding tax slip(s), 3) The Claimant statemont that the tax claimed has not been utilized to reduce the lable tax nor to deduct the taxable income in calculating the liable tax in the Claimant's countryjurisdiction, and 4) Document(s) related to the earned income as mentioned in No. 13.4 Number 14: Please fill in the venue and date of signing, Number 15: ‘The Claimant or the representative must sign the form, Number 16: Please fil in the capacity of the Claimant or the representative who signs this form,MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA serene DIRECTORATE GENERAL OF TAXES rennin Woe ate POWER OF ATTORNEY FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 4) The undersigned: Name 0 Address @ Phone No.( acting as”: ©) the claimant (for Individual) ® 0 the claimant (representative of non individual entity) Information of the claimant: Name @ Taxpayer IDNo. : © Address © Phone No.(_), Country/Jurisdiction : ” herewith gives the power of attorney to (Indonesia withholding tax agent) Name : (8) Taxpayer ID No. © Address 5 (19) Phone No.(_) to lodge the application for claiming tax refund of Indonesia tax withholding (completed Form-DGT 3), including the required attachments, to the Director General of Taxes, and to act on my behalf to receive the tax refund approved by the Director General of Taxes. This power of attorney is made to be used for the purposes so indicated. J 4) Place and date (mmiddiyyyy) 42) (3) 4) Signature of the proxy ‘Signature of he claimant or individual CCapaaty in which acting ‘authorized to sign on behalf ofthe csimant 1 Pace eck he eset be FORMOGT 4INSTRUCTIONS FOR FORM OF POWER OF ATTORNEY (FORM-DGT 4) General information: This form is one of the required documents which granting a power of attorney to Indonesia withholding tax agent to lodge the refund application (completed Form-DGT 3) and all required attachments and to act on behalf the Claimant to teceive any tax refund approved by the Director General of Taxes, It is required to provide an account in any bank situated in Indonesia in Indonesia Rupiah (IDR) currency. Guidance to fill this form: Number 1: Please fil in the name of individual who signs this form. For individual, please fil in the name of the Claimant. For non individual entity, please fil in the name of individual who may act as the representative ofthe entity Number 2: Please fil in the address of individual who will sign the power of attorney. Number 3: Please check the appropriate box. Number 4: Please fil in the Claimant's name. if the Claimant is an individual, the name is as itis filed in Number 1 Number 5: Please fil in the Claimant's taxpayer identification number in countryurisdiction where the claimant registered as a taxpayer resident, Number 6: Please fil in the claimant's address. Number 7: Please fill in the countryjurisdiction where the claimant registered as a taxpayer resident. Number 8-10: Please fil in the information of Indonesia withholding tax agent who receives the power of attorney. The information may be appeared in the withholding tax slip. (@) Please fil n the name of the withholding tax agent, (2) Please fin the taxpayer identification number (NPWP), (10) Please fil in the address. Number 11: Please fil in the venue and date of signing Number 12: ‘The person who receives the power of attorney must sign this form. Number 13: The Claimant, or the representative of non individual claimant, ‘must sign this form. Number 14: Please fil in capacity of the Claimant who signs this form. in case the signor is the representative, please fil in the capacity of the signor. Not ‘The Power of Attorney is liable to Indonesian stamp duty (IDR 6,000) according to Law No.13 Year 1985.MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA mene erssa DIRECTORATE GENERAL OF TAXES senate CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 5) + Do not use this form to claim benefit of Double Taxation Convention/Agreement (OTC) at the time you earn income from the Indonesia withholding tax agent. ‘This form Is only required to be completed by a person (which includes @ body of person, corporate or non corporate) who is a resident of a country/jurisdiction that has concluded a DTC with Indonesia, ‘This form consists of 2 (wo) pages and all particulars are to be properly furnished and this form shall be completed and signed by the claimant, not by the Indonesia withholding tax agent, * Pat Ill must be ceriied by the competent authorities, his authorized representative or the authorized tax office in the country of lursdiction where the claimant is a taxpayer resident. NAME OF COUNTRY/JURISDICTION OF THE CLAIMANT E 0 INFORMATION OF THE CLAIMANT TexiD Number: al Full Name : a Address « PERRIN bc Lsraion Ano STATEMENT OF BENEFICIAL OWNERSHIP BY THE CLAIMANT, _____ © (tu name) hereby dectare that: 1.” 1am (authorized to sign for) the beneficial awner of income stated in the completed Form-DGT 8 (ths statement must be filed ony i the related article inthe DTC mentions the beneficial cwner phrase); 2. Clam 1 This entity is” not an Indonesian taxpayer resident; and 2. | have examined the information provided in this form and to the best of my knowledge and belief itis true, correct, and complete. 6) I o @ __ ®) ‘Signature of he near repent or nddual Date (rida) Capaciyin which acing Coniaei Naber ‘authorized to sign forthe income recent CERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF COUNTRY/JURISDICTION OF RESIDENCE For the purpose of tax relief, it is hereby confirmed that the taxpayer mentioned in Part | is a resident in a (10) frame ofthe courtyureeeton of esence} within the meaning of the Double Taxation ‘Convention/Agreement in accordance with Double Taxation Convention/Agreement concluded between Indonesia and (1) frame ofthe cureyjursicvon of residence 2 neat Date (isc: oT 14 Fame and signature of the Compatont Auton, his “9 futhorized representative or authorized tax ofce (arn Office address: 09) a ‘Capaciividesianation of sicnatov — This form is available and may be downloaded at this website: pilin. was paiak co.idMINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA, we hek Yo ae DIRECTORATE GENERAL OF TAXES ‘eaayarin Pan ae ears an CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 5) PERRI 70 compucten iF rae CLAIMANT Is AN INDIVIDUAL 1. Name —— 0 2. Date of bith (mmisdiyyyy):_/-_|__(07) | 9. Are you acting as an agent ora nominee? a Yes o No” (8) 4. Full adress: . (9) 5. Do you have a pemmanenthome in indonesia? Yes 0 No” @ 6. Country where you reside ordinary en 7. Have you ever been resided in indonesia? “Yes 0 No i180, inwhat period? _j__/ @ And, please provide te adress 8. bo younave any ofice, or the place of business in Indonedia? Yes. o No” 2) Is, please provide the across 8. Is the transaction stuctured by reson only to take advantage of beneftofthe DTC? a Yes _o NO” eH Ea "TO BE COMPLETED IF THE CLAIMANT IS A NON INDIVIDUAL 1. County of registrationfincorporation — - _ 2. Country where the place of management or control resid: - ww 3. Address of Head Office: __ en 4. Address of branches, offices, or other place of business in Indonesia (itany):_ 7 __ 5. Nature of business (Pension Fund, Insurance, Bank, Financing, etc.) ce 6. Is the entity acting as an agent or a nominee? (90) © Yes 3 No? 7. The creation ofthe entity andlor the transaction structure isnot solely motivated by reason Yes a No? to take the advantage of benefit ofthe DTC e 8. The entity is sted in stock market and the shares are regulary traded. If yes, please © Yes a No” provide the name of the stock market: _ Co) 9. The entity has its own management to conduct the business and such management has an Yes > No" independent discretion ry 10. The enlty employs suticiont qualified personnel (os)_a Yes This form is availabe and may be downloaded a this website: ht Jwwre pajak aid +) Please check the appropriate box | declare that | have examined the information provided in this form and to the best of my knowiedge and belief itis true, ‘correct and complete. (95) J__|__(86) 7 8) ‘Signaiure ofthe come recpientor mdvidual Date famidaiyy) — Capactyin whieh acting ‘Gonact Nambar ‘Buthorized to sign forthe income recipient Page 2INSTRUCTIONS FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 5) General information: 1. This form is only required for the Claimant whose ccountryjurisdiction has concluded Double Taxation Convention/Agreement (DTC) with Indonesia. 2. This form consists of 2 (two) pages. The fist page consists of the Claimant dectaration and authorization by the Competent Authority or authorized tax office in the Claimant's countryirisdiction conceming the status of the Glaimant's residency. ‘After the Claimant fils this form completely please bring the first page to the competent authority or authorized tax otfice for authorization, In case the competent authority or the authorized tax office ‘cannot put his authorization in this form, the Claimant may ‘submit the cerificate of domicile, as an attachment of Form- DGT 5, which is usually issued in the Claimant's ‘countryjurisdiction and such certificate shall meet the requirements as provided in the instruction of Form-DGT 5: ‘a. Itmust be written in English b. It states at least the name of the Claimant; It mentions the fiscal year which covers the period when the income, related to the tax claimed, is derived; and d. It bears the signature and the name of the competent authority, his authorized representative or the authorized tax officer. ‘The second page consists of information related to the Claimant which is required to be signed by the Claimant Authorization by the competent authority or authorized tax ‘office is not necessary for information in this second page. Guidance to fill this form: Number 1: Pease fil in the name of country/jurisdiction of the Claimant. Part information of Claimant: Number 2: Please fil in the Claimant's taxpayer identification number in country where the Claimant is registered as a resident taxpayer. Please type “n.a in case the countryrisdiction of the Claimant does not provide taxpayer identification number for resident taxpayers Number 3: Please fil in the Claimant's name Number 4: Please fil in the Claimant's address. Partll Declaration by the Claimant: Number 5: Please ill in the name of person who authorized to sign on behatf the Claimant. If the Claimant is not an individual, this form must be filed by individual who may act as representative of the non individual entity, If the Claimant is an individual, please fil in the name as stated in Number 3, Important: The Claimant is required to state: ‘a. whether the Claimant is the beneficial owner of income. The In case the Claimant is not the beneficial owner, do not check the box, whether the Claimant is the Indonesian taxpayer resident. Do not check the box if the Claimant is Indonesian resident taxpayer, Number 6: The Claimant or his representative (for non individual) must sign this form, Number 7: Please fil in the date of signing. Number 8: Please fil in the capacity of the Claimant or his representative who signs this form, Number 9: Pease fil in the contact number of person who signs this form, ny thority of the count In case the Competent Authority, His authorized representative or the authorized tax office cannot put his authorization in this, ‘orm, the Claimant may leave blank this Part. Then, the Claimant ‘must attach the certificate of domicile, which is commonly issued in the Claimant's country/urisdiction, to the completed Form- bers. Number 10 and 11: Pease fil in the name of countryjurisdiction where the C'aimant is resident taxpayer. Number 12 and 13 ‘The Competent Authorities, his authorized representative, or authorized tax office certifies this form by signing it. The position of the signor should be filed in Number 13, Number 14: Please fil in the date when the form is signed by the competent authority, his authorized representative or authorized tax office Number 15: Please fil in the office address of the competent authority, authorized representative or authorized tax office. Part V_ To be completed if the Claimant is an Individual Number 16: lease fil in the Claimant's fullname, Number 17: Please fil in the Claimant's birthday. Number 18: Please check the appropriate box. You are considered acting as fan agent if you act as an intermediary or acting for and on behalf of other party in relation with the income source in Indonesia. You are considered acting as a nominee if you are the legal ‘owner of income or of assets that the income is generated but ‘not the real owner of the income or assets. Number 19: Please fil in the Claimant's address. ‘Number 20: Please check the appropriate box. If the Claimant's permanent home is in Indonesia, you are considered as Indonesian taxpayer resident in accordance with the Indonesian Income Tax Law. In that case the DTC cannot be applied to the Claimant. Number 21: Please fil the name of country where the Claimant ordinarilyINSTRUCTIONS FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM-DGT 5) Number 22: Please check the appropriate box. In case the Ciaimant has ever boon resided in Indonesia, please fil the period of your stay and address where you resided. Number 23: Please check the appropriate box. In case the Claimant has any offices, or other place of business in Indonesia, please fill in the address of office or other place of business in Indonesia, Number 24: Please state whether or not the Claimant's motivation in ‘structuring the transaction related to the eared income is solely to take advantage of benefit of the DTC. Part V To be Completed if the Claimant is non Individual: Number 25: Please fil in the country/jurisdiction where the entity is registered or incorporated Number 26: Please fil in the country where the entity is controlled or where its management is situated. Number 27: Please fil in the address of the entity's head office. Number 28: Please fil nthe address of any branches, offices or other place of business of the entity situated in Indonesia Number 29: Please fil in the nature of business af the Claimant. Number 30-38: Please check the appropriate box in accordance with the Claimant’ facts and circumstances. (80) Please check “No” if the entity, in relation with the eamed income, is acting as an agent or @ nominee. The meaning of agent oF nominee is mentioned in Number 18, (31) Please state whether or not motivation of the Claimant related to the eared income is solely to take advantage of benefit of the DTC. (32) Please state whether or not the entity is listed in stock ‘market and, if $0, please type the name of the stock market, (33) Please state whether the entity has its own management to conduct the business and such management has an independent discretion (24) Please stato whether the entity employs sufficient qualified personnel Number 35: ‘The Claimant or his representative (for non individual) must sign this form, Number 36: rease fil in the date of signing, Number 37: Please fil in the capacity of the Claimant or his representative ‘who signs this form, Number 38: Please fil in the contact number of person who signs this form.INSTRUCTIONS FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA ‘TAX WITHHOLDING (FORM-DGT 5) General information: 1, This form is only required for the Claimant whose countryursdiction has concluded Double Taxation CConvention/Agreement (DTC) with Indonesia, 2. This form consists of 2 (two) pages. The fist page consists of the Claimant declaration and authorization by the Competent Authority or authorized tax office in the Claimant's country/jurisdiction concerning the status of the Claimant's residency. After the Claimant fils this form completely please bring the {first page to the competent authority or authorized tax office {for authorization In case the competent authority or the authorized tax office cannot put his authorization in this form, the Claimant may submit the certificate of domicile, as an attachment of Form- DGT 5, which is usually issued in the Claimant's country/urisdiction and such certificate shall meet_ the requirements as provided in the instruction of Form-DGT 5: 't must be writen in English; INstates at least the name of the Claimant; ©. It mentions the fiscal year which covers the period ‘when the income, related to the tax claimed, is derived; and 4. It bears the signature and the name of the competent authority, his authorized representative of the authorized tax officer. The second page consists of information related to the Claimant which is required to be signed by the Claimant Authorization by the competent authority or authorized tax office is not necessary for information inthis second page. Guidance to fill this form: Number 1: Please fl in the name of countryjurisdiction of the Claimant. Part | Information of Claimant: Number 2: Please fil in the Claimant's taxpayer identification number in ‘country where the Claimant is registered as a resident taxpayer. Please type “n.a." in case the country/urisdicton of the Ciaimant does not provide taxpayer identification number for resident taxpayers, Number 3: Please filin the Claimant's name. Number 4: Please filin the Claimant's address Part i Declaration by the Claiman Number 5: Please fil in the name of person who authorized to sign on behalf the Claimant. If the Claimant is not an individual, this form must be filed by individual who may act as representative of the non individual entity If the Claimant is an individual, please fil in the name as stated in Number 3, Important: The Claimant is required to state ‘a. whether the Claimant is the beneficial owner of income. The phrase beneficial owner is commonly contained in article of DTC related to the income of dividend, interest, royalties land capital gain (sometimes). It is highly recommended to the Claimant to check article in DTC related to the income. In case the Claimant is not the beneficial owner, do not cheek the box; b. whether the Claimant is the Indonesian taxpayer resident, Do not check the box ifthe Claimant is Indonesian resident taxpayer. Number 6: ‘The Claimant or his representative (for non individual) must sign this form. Number 7: Please fil in the date of signing Number 8: Please fil in the capacity of the Claimant or his representative ‘who signs this form, Number 9: Please fil in the contact number of person who signs this form, rt II|_Certification by competent authority of the countr of residence: In case the Competent Authority, His authorized representative or the authorized tax office cannot put his authorization in this form, the Claimant may leave blank this Part. Then, the Claimant ‘must attach the cerifcate of domicile, which is commonly issued in the Claimant's countryjurisciction, to the completed Form: Drs Number 10 and 11 Please fli the name of countryurisdiction where the Claimant is resident taxpayer. Number 12 and 13 ‘The Competent Authorities, his authorized representative, or authorized tax office cerifies this form by signing it. The position (of the signor should be filed in Number 13, Number 14: Ploase fil in the date when the form is signed by the competent authority, his authorized representative or authorized tax office Number 15: Please fil in the office address of the competent authority, authorized representative or authorized tax office Part IV To be completed if th Individi Number 16: Please fillin the Claimant's fullname, Number 17: Please fillin the Claimant's birthday.