MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA

DIRECTORATE GENERAL OF TAXES

APPLICATION FORM
FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM - DGT 3)

I the undersigned :

Name : (1)

Address : (2)

Phone No. ( )
acting as : *)
the claimant himself - individual the claimant himself - management of non individual entity (3)

Information of the claimant :

Name : (4)

Taxpayer ID No. : (5)

Address : (6)

Phone No. ( )
Country/jurisdiction : (7)

to claim refund for the following tax withheld in Indonesia : (additional paper may be used) (8)

No. Withholding Tax Slip (No. and Date) Tax Withheld (Rupiah) Tax Refund Claimed (Rupiah)
(A) (B) (C)
1.
2.
3.
4.
Total
The above tax as mentioned in column B withheld by Indonesia withholding tax agent :
Name : (9)

Taxpayer ID number : (10)

Address : (11)

Reasons of refund claim : (additional paper may be used) (12)

Document attached : (13) *)

Power of Attorney (completed Form - DGT 4)

Certificate of Domicile (completed Form-DGT 5) (required only if claimant is resident of Indonesia DTC partner)

Orignal withholding Tax slip (s) : piece(s)

Documents to support the statement of beneficial ownership, which consists of 7 items. (required only if claiment is resident of
Indonesian DTC partner and related article(s) in DTC mentions the beneficial owner phrase)

Documents related to the earned income

Statement of Claimant that the tax claimed has not been utilized to reduce the liable tax in the claimant's country/jurisdiction
not to deduct the taxable income in the claimant's country/jurisdiction.
Other document (s), please specify (if any) :

Declaration :
I declare that the information stated in this form is true, correct and complete.

, / /
Place and Date (mm/dd/yyyy) (14) Signature of the claimant or individual Capacity in which acting (16)
authorized to sign for the claimant (15)
*) Please check the appropriate box

FORM-DGT 3