INSTRUCTIONS

FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA
TAX WITHHOLDING (FORM-DGT 5)

In case the Claimant is not the beneficial owner, do not

General information : check the box;
1. This form is only required for the Claimant whose b. whether the Claimant is the Indonesian taxpayer resident .
country/jurisdiction has concluded Double Taxation Do not check the box if the Claimant is Indonesian resident
Convention/Agreement (DTC) with Indonesia . taxpayer .
2. This form consists of 2 (two) pages . The first page consists Number 6 :
of the Claimant declaration and authorization by the The Claimant or his representative (for non individual) must sign
Competent Authority or authorized tax office in the this form .
Claimant's country/jurisdiction concerning the status of the
Claimant's residency . Number 7 :
Please fill in the date of signing .
After the Claimant fills this form completely please bring the
first page to the competent authority or authorized tax office Number 8 :
for authorization . Please fill in the capacity of the Claimant or his representative
who signs this form .
In case the competent authority or the authorized tax office
cannot put his authorization in this form, the Claimant may Number 9 :
submit the certificate of domicile, as an attachment of Form- Please fill in the contact number of person who signs this form .
DGT 5, which is usually issued in the Claimant's
Part III Certification by competent authority of the country
country/jurisdiction and such certificate shall meet the
of residence :
requirements as provided in the instruction of Form-DGT 5:
In case the Competent Authority, His authorized representative
a. It must be written in English ;
or the authorized tax office cannot put his authorization in this
b. It states at least the name of the Claimant ; form, the Claimant may leave blank this Part . Then, the Claimant
must attach the certificate of domicile, which is commonly issued
c. It mentions the fiscal year which covers the period in the Claimant's country/jurisdiction, to the completed Form-
when the income, related to the tax claimed, is derived ; DGT 5 .
and
Number 10 and 11 :
d. It bears the signature and the name of the competent Please fill in the name of country/jurisdiction where the Claimant
authority, his authorized representative or the is resident taxpayer .
authorized tax officer .
Number 12 and 13
The second page consists of information related to the The Competent Authorities, his authorized representative, or
Claimant which is required to be signed by the Claimant . authorized tax office certifies this form by signing it . The position
Authorization by the competent authority or authorized tax of the signor should be filled in Number 13 .
office is not necessary for information in this second page .
Number 14 :
Please fill in the date when the form is signed by the competent
Guidance to fill this form : authority, his authorized representative or authorized tax office

Number 1 :
Number 15 :
Please fill in the name of country/jurisdiction of the Claimant . Please fill in the office address of the competent authority,
Part I Information of Claimant : authorized representative or authorized tax office .
Number 2 :
Please fill in the Claimant's taxpayer identification number in Part IV To be completed if the Claimant is an Individual :
country where the Claimant is registered as a resident taxpayer . Number 16 :
Please type "n .a ." in case the country/jurisdiction of the Claimant Please fill in the Claimant's full name .
does not provide taxpayer identification number for resident
taxpayers . Number 17 :
Number 3 : Please fill in the Claimant's birthday .
Please fill in the Claimant's name .
Number 18 :
Number 4 :
Please fill in the Claimant's address . Please check the appropriate box . You are considered acting as
an agent if you act as an intermediary or acting for and on behalf
Part II Declaration by the Claimant : of other party in relation with the income source in Indonesia .
Number 5 : You are considered acting as a nominee if you are the legal
Please fill in the name of person who authorized to sign on owner of income or of assets that the income is generated but
behalf the Claimant . not the real owner of the income or assets .

If the Claimant is not an individual, this form must be filled by Number 19:
individual who may act as representative of the non individual Please fill in the Claimant's address .
entity .
Number 20:
Please check the appropriate box . If the Claimant's permanent
If the Claimant is an individual, please fill in the name as stated home is in Indonesia, you are considered as Indonesian
in Number 3 . taxpayer resident in accordance with the Indonesian Income Tax
Law . In that case the DTC cannot be applied to the Claimant .
Important :
The Claimant is required to state : Number 21 :
Please fill the name of country where the Claimant ordinarily
a. whether the Claimant is the beneficial owner of income . The
resides .
phrase beneficial owner is commonly contained in article of
DTC related to the income of dividend, interest, royalties
and capital gain (sometimes) . It is highly recommended to
the Claimant to check article in DTC related to the income .
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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 Claimant has ever
been resided in Indonesia, please fill 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 earned 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 fill in the country/jurisdiction where the entity is registered
or incorporated .

Number 26 :
Please fill in the country where the entity is controlled or where
its management is situated .

Number 27 :
Please fill in the address of the entity's head office .

Number 28 :
Please fill in the address of any branches, offices or other place
of business of the entity situated in Indonesia .

Number 29 :
Please fill in the nature of business of the Claimant .

Number 30-38 :
Please check the appropriate box in accordance with the
Claimant's facts and circumstances .

(30) Please check "No" if the entity, in relation with the earned
income, is acting as an agent or a nominee . The meaning of
agent or nominee is mentioned in Number 18 .
(31) Please state whether or not motivation of the Claimant
related to the earned 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 so, 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 .
(34) Please state whether the entity employs sufficient qualified
personnel .
Number 35 :
The Claimant or his representative (for non individual) must sign
this form .
Number 36:
Please fill in the date of signing .

Number 37 :
Please fill in the capacity of the Claimant or his representative
who signs this form .

Number 38 :
Please fill in the contact number of person who signs this form .
R
F

INSTRUCTIONS
FOR CERTIFICATE OF DOMICILE OF NON RESIDENT FOR CLAIMING TAX REFUND OF INDONESIA
TAX WITHHOLDING (FORM-DGT 5)

General information :
If the Claimant is an individual, please fill in the name as stated
1. This form is only required for the Claimant whose in Number 3 .
country/jurisdiction has concluded Double Taxation
Convention/Agreement (DTC) with Indonesia . Important :

2. This form consists of 2 (two) pages . The first page consists The Claimant is required to state :
of the Claimant declaration and authorization by the
Competent Authority or authorized tax office in the a. whether the Claimant is the beneficial owner of income . The
phrase beneficial owner is commonly contained in article of
Claimant's country/jurisdiction concerning the status of the
DTC related to the income of dividend, interest, royalties
Claimant's residency .
and capital gain (sometimes) . It is highly recommended to
After the Claimant fills this form completely please bring the the Claimant to check article in DTC related to the income .
first page to the competent authority or authorized tax office In case the Claimant is not the beneficial owner, do not
for authorization . check the box;
In case the competent authority or the authorized tax office b. whether the Claimant is the Indonesian taxpayer resident .
cannot put his authorization in this form, the Claimant may Do not check the box if the Claimant is Indonesian resident
submit the certificate of domicile, as an attachment of Form- taxpayer .
DGT 5, which is usually issued in the Claimant's
Number 6 :
country/jurisdiction and such certificate shall meet the
requirements as provided in the instruction of Form-DGT 5 : The Claimant or his representative (for non individual) must sign
this form .
a. It must be written in English ;
Number 7 :
b. It states at least the name of the Claimant ; Please fill in the date of signing .
c. It mentions the fiscal year which covers the period Number 8 :
when the income, related to the tax claimed, is derived ; Please fill in the capacity of the Claimant or his representative
and who signs this form .

d. It bears the signature and the name of the competent Number 9 :

authority, his authorized representative or the Please fill in the contact number of person who signs this form .
authorized tax officer . Part Ill Certification bV competent authority of the country
The second page consists of information related to the of residence :
Claimant which is required to be signed by the Claimant .
In case the Competent Authority, His authorized representative
Authorization by the competent authority or authorized tax
or the authorized tax office cannot put his authorization in this
office is not necessary for information in this second page .
form, 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/jurisdiction, to the completed Form-
Guidance to fill this form : DGT 5 .
Number 1 : Number 10 and 11 :
Please fill in the name of country/jurisdiction of the Claimant . Please fill in the name of country/jurisdiction where the Claimant
Part I Information of Claimant : is resident taxpayer .

Number 2 : Number 12 and 13

Please fill in the Claimant's taxpayer identification number in The Competent Authorities, his authorized representative, or
country where the Claimant is registered as a resident taxpayer . authorized tax office certifies this form by signing it . The position
Please type "n .a ." in case the country/jurisdiction of the Claimant of the signor should be filled in Number 13 .
does not provide taxpayer identification number for resident Number 14 :
taxpayers . Please fill in the date when the form is signed by the competent
Number 3 : authority, his authorized representative or authorized tax office
Please fill in the Claimant's name .
Number 15 :
Number 4 : Please fill in the office address of the competent authority,
Please fill in the Claimant's address .
authorized representative or authorized tax office .
Part II Declaration by the Claimant :
Part IV To be completed if the Claimant is an Individual :
Number 5 :
Please fill in the name of person who authorized to sign on Number 16 :
behalf the Claimant. Please fill in the Claimant's full name .
If the Claimant is not an individual, this form must be filled by
individual who may act as representative of the non individual Number 17 :
entity . Please fill in the Claimant's birthday .