五、非居民纳税人应如实完整填写本表所列问题。如非居民纳税人没有问题所列情况，请在表格中填“无”。本表所列选择题，请非居民纳税人在符合自身情况的选项对应的□或○中打勾“√”。带有*标识的题目，请具有题目所描述情况的非居民纳税人填写，与题目所描述情况不符的非居民纳税人无需填写。

V. The non-resident taxpayer shall provide accurate and complete information to answer the questions contained in the form. Please write “N/A”in the form if a situation described in a question is not applicable for a non-resident taxpayer. For a multiple-choice question, please mark “√” in a corresponding box (“□”) or circle (“○”) for a choice that fits a non-resident taxpayer’s situation. If non-resident taxpayer’s situation falls into the description of a question marked with “*”, answers shall be provided; otherwise, it can be skipped.

六、本表采用中英文双语制作，如中英文表述不一致，以中文为准。如无特别说明，应使用中文填写。

VI. This form is prepared in Chinese and English. In case of divergence in the two languages, the Chinese text shall prevail. Unless otherwise stated, it shall be completed in Chinese.

七、本表各栏填写如下：

VII. Instructions on how to fill in each item are as follows: （一）扣缴义务人基本信息

(I) Basic Information of Withholding Agent

1. 扣缴义务人名称：由扣缴义务人填写税务登记证所载扣缴义务人的全称。

Name of withholding agent: The withholding agent should provide its full name as shown in its tax registration certificate.

2. 扣缴义务人纳税人识别号：由扣缴义务人填写扣缴义务人税务登记证上注明的“纳税人识别号”。

Tax identification number of withholding agent: The withholding agent should provide its identification number as shown in the tax registration certificate.

（二）非居民纳税人基本信息

(II) Basic Information of Non-resident Taxpayer

3.非居民纳税人中文名称：填写非居民纳税人在中国境内的中文全称。

Chinese name of non-resident taxpayer: Fill in the full Chinese name used by the non-resident taxpayer in China.

4.非居民纳税人在居民国（地区）名称：填写非居民纳税人在其居民国（地区）的英文全称。

Name of non-resident taxpayer in resident state (region): Fill in the full English name of the non-resident taxpayer which is used in the non-resident taxpayer’s state (region) of residence.

5.所得类型：非居民纳税人根据取得所得的实际类型选择。第三、四部分仅需填写就所选类型所得享受税收协定待遇相关的题目，及“其他信息”中的共性题目。

Type of income: The non-resident taxpayer should select the type of income actually received; In Part III and Part IV one should only fill in items related to enjoying tax treaty benefits for the selected type of income, and for those common items in “Other information”.

（三）扣缴义务人使用信息

(III) Information for Use by Withholding Agent

6.问题4，非居民纳税人直接或间接拥有支付股息公司的股份比例合计和非居民纳税人在该公司的投资金额：非居民纳税人需享受的税收协定股息条款有相关限制性规定的，非居民纳税人须填写此题，其中币种应填写税收协定列明币种。其他情况无需填写。

Question 4, “Percentage of total share capital held, directly and indirectly, by the non-resident taxpayer in the dividend paying company” and “Amount of investment in the dividend paying company by the non-resident taxpayer”: If the dividend article of the tax treaty, which the non-resident taxpayer is entitled to enjoy, contains such a limiting condition then the non-resident taxpayer should answer this question; for “Currency”, the currency specified in the tax treaty shall be filled in. In circumstances where these questions are not relevant they can be skipped.

7.问题8，贷款资金是否存在以下情况：非居民纳税人需享受的税收协定利息条款有相关限制性规定，且非居民纳税人需依据该规定享受税收协定待遇的，须填写此题。非居民纳税人填写此题后须在问题9中写明符合条件的政府或机构全称。其他情况无需填写。

Question 8, “Do any of the following circumstances apply in respect of the loaned monies?”: If the interest article of the tax treaty, which the non-resident taxpayer is entitled to enjoy, contains such a limiting condition, and the non-resident taxpayer in accordance with this condition is entitled to treaty benefits, then the non-resident taxpayer should answer this question. The non-resident taxpayer shall provide the full name of the government or institution, where the loan circumstances accord with the terms of the treaty relief, in Question 9 that follows. In circumstances where these questions are not relevant they can be skipped.

8.问题12，请简要描述据以产生特许权使用费所得的具体权利或财产：请对据以产生特许权使用费所得的权利或财产的类型进行具体说明，如属于何种专利、著作权，租赁何种设备等。并请说明特许权使用费的支付条件和计算标准。

Question 12, “Please give a brief description of the specific right or property from which the royalty income derives.”: Please provide specific details of the rights or property from which the royalty income derives, such as the type of the patent, copyright and equipment leased. Information about the payment terms and calculation basis of the royalties shall also be provided.

9.问题13，该项所得是否与非居民纳税人设在中国的常设机构或固定基地有实际联系：常设机构是指非居民企业或个人在中国进行全部或部分营业的固定营业场所。固定基地是指从事独立个人劳务活动的人员从事其业务活动的固定场所（地点）。如该项所得与非居民纳税人设在中国的常设机构或固定基地有实际联系，则该项所得应纳入常设机构的营业利润征税，或纳入独立个人劳务所得征税，不能享受股息、利息或特许权使用费条款税收协定待遇。

Question 13, “Is the income effectively connected with a permanent establishment or fixed base of the non-resident taxpayer in China?”: A permanent establishment refers to a fixed place of business through which the business of a non-resident enterprise or individual is wholly or partly carried on in China. A fixed base refers to a fixed place (location) through which an individual engaging in independent personal services conducts his or her business activities. If the income is effectively connected with a permanent establishment or a fixed base of a non-resident taxpayer in China, the income shall be taxed as part of the profits of the permanent establishment, or as part of the individual’s income from independent personal services, and may not be deemed eligible for tax treaty

benefits under the dividends, interest or royalties articles.

10.问题14，非居民纳税人是否通过代理人取得该项所得：代理人包括指定收款人。如非居民纳税人是通过代理人取得该项所得，需在申报享受税收协定待遇时向主管税务机关提交代理人不具有受益所有人身份的声明。如非居民纳税人通过委托投资取得该项所得，需在申报享受税收协定待遇时向主管税务机关提交《国家税务总局关于委托投资情况下认定受益所有人问题的公告》（国家税务总局公告2014年第24号）规定的报告资料。

Question 14, “Did the non-resident taxpayer receive the income via an agent?”: An agent includes a designated payee. If the income was received by a non-resident taxpayer through an agent, the non-resident taxpayer shall submit a statement to the in-charge tax authority, at the time of filing for tax treaty benefits, confirming that the agent does not act in the capacity of a beneficial owner. If the non-resident taxpayer receives the income through an entrusted investment arrangement, the non-resident taxpayer shall submit to in-charge tax authority, at the time of filing for tax treaty benefits, reporting materials as required by the Announcement of the State Administration of Taxation on Identifying a Beneficial Owner under an Entrusted Investment (Announcement of the State Administration of Taxation No. 24, 2014).

11.问题15，非居民纳税人为该项所得的“受益所有人”的声明：“非居民纳税人是否对所得或所得据以产生的财产或权利具有控制权或处置权”，根据非居民纳税人对所得据以产生的财产或权利和所得本身是否可以依自身意愿支配（即行使控制权或处置权不受任何关联或非关联的第三方影响）进行判断。“非居民纳税人是否对所得或所得据以产生的财产或权利承担相应风险”，根据非居民纳税人是否需承担所得据以产生的财产或权利和所得本身因各种不确定因素而遭受的损失进行判断，如果非居民纳税人很少承担风险或所得和风险不匹配，也应选择“否”。“非居民纳税人据以取得该项所得的有关权利或财产是否为获得税收协定的减免税利益而安排”，非居民纳税人应如实回答是否存在通过不具合理商业目的安排获得税收协定利益、滥用税收协定、减少或逃避非居民纳税人在中国纳税义务的情形。非居民纳税人需对自身的受益所有人身份进行声明，因与声明不符而出现的逃避税等问题将按照相关税收法律规定进行处理。

Question 15, “Statement by non-resident taxpayer as the ‘beneficial owner’ of the income”: “Does the non-resident taxpayer have control over or the right to dispose of the income or the property or rights from which such income derives?” shall be answered based on whether the non-resident taxpayer can dispose of the income-earning property or rights, or the income itself, at its own discretion (namely, exercising control or disposal rights free of the influence of any related or non-related parties). “Does non-resident taxpayer bear the risks associated with the income or the property or rights from which such income derives?” shall be evaluated based on whether the non-resident taxpayer must bear the losses arising from uncertainties impacting on the income-earning property or rights and on the income itself; if the non-resident taxpayer seldom bears such risks or the income and risks do not match, “No” shall be selected.

“With respect to the property or rights from which the non-resident taxpayer derives the income, have arrangements been made in such a way so as to gain access to the treaty benefits of tax exemption or reduction?” shall be honestly answered by a non-resident taxpayer based on whether an arrangement without a reasonable commercial purpose is used to gain tax treaty benefits, abuse a tax treaty and/or reduce or avoid the non-resident taxpayer’s tax-paying duties in China. A non-resident taxpayer shall make a

statement concerning its identity as the beneficial owner and shall be held accountable under relevant tax law for tax avoidance and other violations arising from an untrue statement.

12.问题16，享受税收协定待遇的优惠税率（或实际征收率）：填写享受税收协定待遇的优惠税率。如税收协定规定以特许权使用费总额的70%为基数，则填写实际征收率为7%，如税收协定规定对该项所得免税，则填写实际征收率为0。非居民纳税人所填优惠税率（或实际征收率）须与纳税申报表或扣缴申报表保持一致。

Question 16, “Preferential tax rate under tax treaty treatment (or actual tax rate)”: Fill in the preferential tax rate applying under the tax treaty. If the tax treaty prescribes that 70% of the total royalties shall be used as a base, write 7% as the actual tax rate; if the tax treaty grants a tax exemption on the income, write 0 as the actual tax rate. The preferential tax rate (or actual tax rate) filled in by a non-resident taxpayer shall match that on the Tax Filing Form or Withholding Declaration Form.

（四）税务机关管理采集信息

(IV) Information for Use by Tax Authorities

13.问题17，非居民纳税人是否为税收协定缔约对方的上市公司：如非居民纳税人取得的是股息所得，且非居民纳税人是税收协定缔约对方上市的公司，则非居民纳税人无需填写问题29-34，但须填写问题19上市证券交易所名称和上市股票代码。

Question 17, “Is non-resident taxpayer a listed company in a tax treaty contracting party state?”: If the non-resident taxpayer earns the income from dividends, and is a listed company in a tax treaty contracting party state, Question 29 to 34 can be skipped, but the name of the stock exchange on which the company is listed and its stock code in Question 19 shall be provided.

14.问题18，非居民纳税人是否为税收协定缔约对方居民且在缔约对方上市的公司100%直接或间接拥有：如非居民纳税人取得的是股息所得，且非居民纳税人符合问题所述条件，则非居民纳税人无需填写问题29-34，但须填写问题19上市证券交易所名称和上市股票代码。

Question 18, “Is the non-resident taxpayer held 100%, directly or indirectly, by a resident of the other tax treaty contracting party, which is a listed company in the other tax treaty contracting party as well?”: If a non-resident taxpayer earns the income from dividends, and fits the situation described in the question, Question 29 to 34 can be skipped, but the name of the stock exchange on which the company is listed and its stock code in Question 19 shall be provided.

15.问题23，请简要说明非居民纳税人与第三人之间合同情况：请说明第三人身份及第三人与非居民纳税人之间的关联关系，非居民纳税人与第三人之间合同的数额、利率、期限、签订时间、付息与还款条件、担保人等合同要素，以及该合同与需享受税收协定待遇的该项所得之间的联系。

Question 23, “Please give a brief account of the contract(s) entered into between the non-resident taxpayer and the third party.”: Please identify the third party and provide information with regard to the relationship between the third party and the non-resident taxpayer, such contract information as the amount, interest rate, duration, date of signature, interest-paying and repayment terms and guarantor, as well as the relationship between the contract(s) and the income to be considered for tax treaty benefits.

16.问题27，请简要说明非居民纳税人与第三人之间合同情况：请说明第三人身份及第