MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA (FORM DGT-1)

DIRECTORATE GENERAL OF TAXES

CERTIFICATE OF DOMICILE OF NON RESIDENT

FOR INDONESIA TAX WITHHOLDING

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 :

Tax ID Number : (Please insert Tax ID Number) (2)

Name : (3)

Full Address : (4)

Contact Number : (5) email : (6)

Part II DECLARATION BY THE INCOME RECIPIENT :

I, (full name) (7) 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, a
complete. I further declare that I am X this company is not an Indonesia resident taxpayer.
(Please check the box accordingly)

(8) , / / (9) (10)

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

CERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF THE COUNTRY OF

Part III
RESIDENCE :

For the purpose of tax relief , it is hereby confirmed that the taxpayer mentioned in part I is a resident in
(11) for the period (12) to (13) of the fiscal year (14) within
the meaning of the Double Taxation Convention in accordance with Double Taxation Convention concluded between
Indonesia and (15)

Official
Stamp
(16) (if any) (17) / / (18)
Name and Signature of the Competent Authority or Capacity/designation of signatory Place, date (mm/dd/yy)
his authorized representative or authorized tax office

Office address:

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

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This certificate is valid for 12 (twelve) months commencing from the date of certification
Part IV INDONESIAN WITHHOLDING AGENT

Tax ID Number : 01.131.287.3-062.000 (20)

Name : PT Asuransi Tri Pakarta (21)

Full address : Tripakarta Insurance Building, Head Office Jl. Falatehan, No. 17-19, Jakarta 12160 - 4th Floor (22)

Contact Numbe : 021-7222717 (23) email : [email protected] (24)

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

1. Name of Income Recipient : (25)

2. Date of birth (mm/dd/yyyy) : / / (26)

3. Full address : (27)

4. One of the principal purposes of the arrangements or transactions is to obtain Yes No (28)

benefit under the convention and contrary to the object and purpose of DTC
5. Are you acting as an agent or a nominee? Yes No (29)

6. Do you have permanent home In Indonesia? Yes No (30)

7. In what country do you ordinarily reside? (31)

8. Have you ever been reside In Indonesia? Yes No (32)

If so, In what period? / / to / /

Please provide the address :

9. Do you have any office, or other place of business In Indonesia? Yes No (33)

If so please provide the address :

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

1. Country of registration/incorporation : (34)

2. Which country does the place of management or control reside ? (35)

3. Address of Head Office : (36)

4. Address of branches, offices, or other place of business in Indonesia (if any) : (37)

5. One of the principal purposes of the arrangements or transactions is to obtain Yes X No (38)

benefit under the convention and contrary to the object and purposes of the DTC.
6. There are relevant economic motives or other valid reason for the X Yes No (39)

establisment of the foreign entity

7. The entity has Its own management to conduct the business and X Yes No (40)

such management has an independent discretion.

8. The entity has sufficient assets to conduct business other than the assets X Yes No (41)

generating income from Indonesia

9. The entity has sufficient and qualified personel to conduct the business. X Yes No (42)

10. The entity has business activity other than receiving dividend, interest, X Yes No (43)

royalty sourced from Indonesia.

I 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.

(44) , / / (45) (46)

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

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

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Part VII TO BE COMPLETED IF THE INCOME EARNED ARE DIVIDEND INTEREST OR ROYALTY

1. The entity is acting as an agent, nominee or conduit. Yes No (47)

2. The entity has controling rights or disposal right on the Income Yes No (48)

or the assets or right that generate the Income.

3. No more than 50 per cent of the entity's Income is used to satisfy claims by Yes No (49)

other persons.
4. The entity bear the risk on its own asset, capital, or the liability. Yes No (50)

5. The entity has contract/s which obliges the entity to transfer the income Yes No (51)

received to resident of third country.

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

1. Dividend, Interest, Royalties:

a. Type of Income : (52)

b. Amount of Income liable to withholding tax under Indonesian Law : IDR (53)

c. Amount of Income liable to withholding tax under DTC :

d. Amount : (54) Percentage : (55)

2. Income from rendering services (Including profesional) :

a. Type of Income : (56)

b. Amount of Income liable to withholding tax under Indonesian Law : IDR (57)

c. Amount of Income liable to withholding tax under DTC :

d. Amount : (58) Percentage : (59)

d. Period of engagement (mm/dd/yy) : (60)

/ / to / /
/ / to / /
/ / to / /
/ / to / /

3. Other Type of Income :

a. Type of Income : (61)

b. Amount of Income liable to withholding tax under Indonesian Law : (62)

c. Amount of Income liable to withholding tax under DTC :

d. Amount : USD 19.409,46 (63) Percentage : 0 (64)

I 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.

(68) , / / (66) (67)

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

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

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