非居民纳税人享受税收协定待遇情况报告表（企业所得税A表）
Reporting Form for Non-resident Taxpayer Claiming Tax Treaty Benefits
(Form A for Enterprise Income Tax)
（享受税收协定股息、利息、特许权使用费条款待遇适用）
(Applicable to Tax Treaty Benefits under Articles of Dividends, Interest or Royalties)
填表日期： 年 月 日 Filling date: Y M D
货币单位：元人民币 Currency unit: RMB
○ 自行申报 ○ 扣缴申报 ○ 退税 Self-declaration Withholding declaration Tax refund 一、扣缴义务人基本信息 I. Basic Information of Withholding Agent 扣缴义务人纳税人扣缴义务人名称 Name of withholding agent 识别号 Tax identification number of withholding agent 二、非居民纳税人基本信息 II. Basic Information of Non-resident Taxpayer 非居民纳税人中文名称 Chinese name of non-resident taxpayer 非居民纳税人在居民国（地区）的名称 Name of non-resident taxpayer in resident state (region) 非居民纳税人在中国的纳税人识别号 Tax identification number of non-resident taxpayer in China 非居民纳税人在居民国（地区）纳税人识别号 Tax identification number of non-resident taxpayer in resident state (region) 非居民纳税人享受税收协定名称 Name of the applicable tax treaty 所得类型 Type of income ○ 股息 Dividends ○ 利息 Interest ○ 特许权使用费 Royalties 三、扣缴义务人使用信息III. Information for Use by Withholding Agent （一）享受股息条款待遇 (I) Claiming Tax Treaty Benefits under the Article of Dividends 1．非居民纳税人类型 Type of non-resident taxpayer （1）□政府、政府机构 Government or governmental body （2）□税收协定缔约对方政府直接或间接拥有至少20%股份的缔约对方居民公司 Resident company of the other tax treaty contracting party with no less than 20% of its shares held by the government of the other contracting party, whether directly or indirectly （3）□税收协定缔约对方政府直接或间接全部拥有资本的其他实体 Other entity with all its capital held by the government of the other tax treaty contracting party, whether directly or indirectly （4）□其他公司 Other companies （5）□合伙企业 Partnership enterprises （6）□其他组织类型 请说明 Please specify：_____________________________________________ Other types of entity 2．非居民纳税人直接拥有支付股息的公司的股份比例 Direct shareholding percentage of the non-resident taxpayer in the dividend paying company 3．非居民纳税人直接拥有股份比例在取得股息前的12个月内是否曾有低于25%（不含25%）的情况？ Has the direct shareholding percentage of the non-resident taxpayer in the dividend paying company been less than 25% (excluding 25%) at any time during the 12 months prior to the declaration of the dividends? □ 是 Yes □ 否 No *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 Percentage of total share capital held, directly and indirectly, by the non-resident taxpayer in the dividend paying company 非居民纳税人在该公司的投资金额 Amount of investment in the dividend paying company by the non-resident taxpayer （二）享受利息条款待遇 (II) Claiming Tax Treaty Benefits under the Article of Interest 5．非居民纳税人是否是税收协定列明利息所得免税组织或机构？ Is the non-resident taxpayer listed as an organization or institution specifically exempt from source country tax on interest in the tax treaty? 6．非居民纳税人类型 Type of non-resident taxpayer （1）□税收协定缔约对方的政府、行政区、地方当局 Government, political subdivision, local authority of the other tax treaty contracting party （2）□税收协定缔约对方中央银行 Central Bank of the other tax treaty contracting party （3）□银行 Bank （4）□其他金融机构 Other financial institution （5）□其他企业或组织 Other business or organization 7．非居民纳税人是否完全为税收协定缔约对方的政府所有？ Is the non-resident taxpayer wholly-owned by the government of the other tax treaty contracting party? *8．贷款资金是否存在以下情况 Do any of the following circumstances apply in respect of the loaned monies? （1）□由税收协定缔约对方符合条件的政府或机构间接提供资金 The loaned monies are indirectly provided by government or institution of the other tax treaty contracting party in circumstances in which such indirectly financed loans qualify for benefits under the terms of the treaty （2）□由税收协定缔约对方符合条件的政府或机构提供担保 A guarantee is provided by a government or institution of the other tax treaty contracting party in circumstances in which such guaranteed loans qualify for benefits under the terms of the treaty （3）□由税收协定缔约对方符合条件的政府或机构提供保险 Insurance is provided by a government or institution of the other tax treaty contracting party in circumstances in which such insured loans qualify for benefits under the terms of the treaty □ 是 Yes □ 否 No □ 是 Yes □ 否 No 金额： Amount: 币种： Currency: *9．如贷款资金由税收协定缔约对方符合条件的政府或机构间接提供资金或担保或保险，请填写符合条件的政府或机构全称 Please provide the full name of the qualified government or institution if loans/funds, a guarantee or insurance are indirectly provided by a qualified government or institution of the other tax treaty contracting party （三）享受特许权使用费条款待遇 (III) Claiming Tax Treaty Benefits under the Article of Royalties 10．据以产生该项特许权使用费的权利或财产属于以下哪种类型？ To which of the following types of right or property do the royalties fall into? （1）□文学、艺术或科学著作 Literature, artistic or scientific work （2）□专利、商标、设计、模型、图纸、秘密配方或秘密程序 Patent, trade mark, design, model, plan, secret formula or process （3）□工业、商业、科学设备 Equipment for industrial, commercial or scientific use （4）□有关工业、商业、科学经验的信息 Information concerning industrial, commercial and scientific experience （5）□其他特许权使用费 Other royalties 11．该所得是否属于飞机、船舶租赁所支付的特许权使用费？ Is the income attributable to a royalty paid for aircraft leasing or ship chartering? 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。 □ 是 Yes □ 否 No Please give a brief description of the specific right or property from which the royalty income derives. （四）其他信息 (IV) Other Information 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？ Is the income effectively connected with a permanent establishment or fixed base of the non-resident taxpayer in China? □ 是 Yes □ 否 No 14．非居民纳税人是否通过代理人取得该项所得？ Did the non-resident taxpayer receive the income via an agent? □ 是 Yes □ 否 No