fortaxescoveredbythetaxtreatyonly)税种名称Nameoftax(1)(2)(3)11.根据第三国(地区)法律规定,非居民纳税人同时还构成哪些国家(地区)的税收居民(涉及多个国家或地区请全部列明)?Doesthenon-residenttaxpayerqualifyasataxresidentofanyotherstates(regions)basedonthelawsofsuchstates(regions)?Ifyes,pleasespecifythenamesofallsuchstates(regions).*12.非居民纳税人需享受的税收协定如包含“利益限制”条款或“享受协定优惠的资格判定”条款,请简要说明非居民纳税人是否符合相关条款要求。Ifthetreatycontainsprovisionsof"LimitationonBenefits"or"EntitlementtoBenefits",pleasebrieflydescribewhetherthenon-residenttaxpayermeetstherequirementsoftheseprovisions.五、备注Ⅴ.AdditionalNotes六、声明Ⅵ.Declaration我谨声明以上呈报事项真实、准确、无误。Iherebydeclarethattheinformationgivenaboveistrue,accurateanderror-free.非居民纳税人签章Sealofnon-residenttaxpayer年月日代表人签字SignatureoftherepresentativeYMD扣缴义务人公章:Sealofthewithholdingagent:经办人:Signatureofthecasehandler:填表日期:年月日Dateoffiling:YMD
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