• 31.12.1997 N -6-06/928 " 16.05.1995 N 34"

    11


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    ----------------
       XX  X
    L--L--L--L--L--L--L--L--
    -------------------------------------------------------------------
       1011DT(1997)                                   
    Enclosure to the form 1011DT(1997)                                
    ---------------------------------------  -   
                                                
    L--------------------------------------- name of foreign entity   
                                                                      
    -------------------------   --T-T-T-T-T-    (  4)  
                                      Date (from paragraph 4) 
    L-------------------------   L-+-+-+-+-+--                         Sheet N
    L-------------------------------------------------------------------
    -----------------------------------------------------------------------------
                                                       
     Information about source of income                                         
    +---                                                                        
     1.       ---------------------------------------      --T-
    +---- Type of income                                           Number   
                        L---------------------------------------           L-+--
    +----------------------------------------------------------------------------+
               --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
     Contractor                                           
                   Name in full      L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                                     --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                                                          
                                     L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                          ------------------------------------------
                   Full address                                               
                                     L------------------------------------------
                                          --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                   Identification tax number                  
                                             L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
             ------------------------------       --T-T-T-T-T-
    Contract     Number                                   Date         
                         L------------------------------           L-+-+-+-+-+--
    +-------------------------------------------------------+--------------------+
               --T-T-T-T-T-T-T-T-T-T-T-                     
                                                  
                    L-+-+-+-+-+-+-+-+-+-+-+--            
    Gross amount of income                     Currency code     
    in whole currency units            --T-T-T-T-T-                     
                             Date of accrued               --T-T-      
                             of income       L-+-+-+-+-+--                 
    +-------------------------------------------------------+       L-+-+--      
           --T-T-T-T-T-T-T-T-T-T-T-                     
    Tax withheld                                                  
                                 L-+-+-+-+-+-+-+-+-+-+-+--                     
    +-------------------------------------------------------+--------------------+
     ,      --T-T-T-T-T-T-T-T-T-T-T-     --T-
                              Tax Rate     
    Tax under the Treaty         L-+-+-+-+-+-+-+-+-+-+-+--                 L-+--
    L-----------------------------------------------------------------------------

    -----------------------------------------------------------------------------
    +---                                                                        
     2.       ---------------------------------------      --T-
    +---- Type of income                                         Number     
                        L---------------------------------------           L-+--
    +----------------------------------------------------------------------------+
               --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
     Contractor                                           
                   Name in full      L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                                     --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                                                          
                                     L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                          ------------------------------------------
                   Full address                                               
                                     L------------------------------------------
                                          --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                   Identification tax number                  
                                             L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
             ------------------------------       --T-T-T-T-T-
    Contract     Number                                   Date         
                         L------------------------------           L-+-+-+-+-+--
    +-------------------------------------------------------+--------------------+
               --T-T-T-T-T-T-T-T-T-T-T-                     
                                                  
                    L-+-+-+-+-+-+-+-+-+-+-+--            
    Gross amount of income                     Currency code     
    in whole currency units            --T-T-T-T-T-                     
                             Date of accrued               --T-T-      
                             of income       L-+-+-+-+-+--                 
    +-------------------------------------------------------+       L-+-+--      
           --T-T-T-T-T-T-T-T-T-T-T-                     
    Tax withheld                                                  
                                 L-+-+-+-+-+-+-+-+-+-+-+--                     
    +-------------------------------------------------------+--------------------+
     ,      --T-T-T-T-T-T-T-T-T-T-T-     --T-
                              Tax Rate     
    Tax under the Treaty         L-+-+-+-+-+-+-+-+-+-+-+--                 L-+--
    L-----------------------------------------------------------------------------

    -----------------------------------------------------------------------------
    +---                                                                        
     3.       ---------------------------------------      --T-
    +---- Type of income                                         Number     
                        L---------------------------------------           L-+--
    +----------------------------------------------------------------------------+
               --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
     Contractor                                           
                   Name in full      L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                                     --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                                                          
                                     L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                          ------------------------------------------
                   Full address                                               
                                     L------------------------------------------
    L-----------------------------------------------------------------------------

    ----------------
      X  X X
    L--L--L--L--L--L--L--L--
      Form 1011DT(1997)                                   . Page 2
    -----------------------------------------------------------------------------
                                --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
     Contractor  Identification tax number                    
                                             L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
             ------------------------------       --T-T-T-T-T-
    Contract     Number                                   Date         
                         L------------------------------           L-+-+-+-+-+--
    +-------------------------------------------------------+--------------------+
               --T-T-T-T-T-T-T-T-T-T-T-                     
                                                  
                    L-+-+-+-+-+-+-+-+-+-+-+--            
    Gross amount of income                     Currency code     
    in whole currency units            --T-T-T-T-T-                     
                             Date of accrued               --T-T-      
                             of income       L-+-+-+-+-+--                 
    +-------------------------------------------------------+       L-+-+--      
           --T-T-T-T-T-T-T-T-T-T-T-                     
    Tax withheld                                                  
                                 L-+-+-+-+-+-+-+-+-+-+-+--                     
    +-------------------------------------------------------+--------------------+
     ,      --T-T-T-T-T-T-T-T-T-T-T-     --T-
                              Tax Rate     
    Tax under the Treaty         L-+-+-+-+-+-+-+-+-+-+-+--                 L-+--
    L-----------------------------------------------------------------------------

    -----------------------------------------------------------------------------
    +---                                                                        
     4.       ---------------------------------------      --T-
    +---- Type of income                                         Number     
                        L---------------------------------------           L-+--
    +----------------------------------------------------------------------------+
               --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
     Contractor                                           
                   Name in full      L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                                     --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                                                          
                                     L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                          ------------------------------------------
                   Full address                                               
                                     L------------------------------------------
                                          --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                   Identification tax number                  
                                             L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
             ------------------------------       --T-T-T-T-T-
    Contract     Number                                   Date         
                         L------------------------------           L-+-+-+-+-+--
    +-------------------------------------------------------+--------------------+
               --T-T-T-T-T-T-T-T-T-T-T-                     
                                                  
                    L-+-+-+-+-+-+-+-+-+-+-+--            
    Gross amount of income                     Currency code     
    in whole currency units            --T-T-T-T-T-                     
                             Date of accrued               --T-T-      
                             of income       L-+-+-+-+-+--                 
    +-------------------------------------------------------+       L-+-+--      
           --T-T-T-T-T-T-T-T-T-T-T-                     
    Tax withheld                                                  
                                 L-+-+-+-+-+-+-+-+-+-+-+--                     
    +-------------------------------------------------------+--------------------+
     ,      --T-T-T-T-T-T-T-T-T-T-T-     --T-
                              Tax Rate     
    Tax under the Treaty         L-+-+-+-+-+-+-+-+-+-+-+--                 L-+--
    L-----------------------------------------------------------------------------

    -----------------------------------------------------------------------------
    +---                                                                        
     5.       ---------------------------------------      --T-
    +---- Type of income                                         Number     
                        L---------------------------------------           L-+--
    +----------------------------------------------------------------------------+
               --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
     Contractor                                           
                   Name in full      L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                                     --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                                                          
                                     L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                          ------------------------------------------
                   Full address                                               
                                     L------------------------------------------
                                          --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                   Identification tax number                  
                                             L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
             ------------------------------       --T-T-T-T-T-
    Contract     Number                                   Date         
                         L------------------------------           L-+-+-+-+-+--
    +-------------------------------------------------------+--------------------+
               --T-T-T-T-T-T-T-T-T-T-T-                     
                                                  
                    L-+-+-+-+-+-+-+-+-+-+-+--            
    Gross amount of income                     Currency code     
    in whole currency units            --T-T-T-T-T-                     
                             Date of accrued               --T-T-      
                             of income       L-+-+-+-+-+--                 
    +-------------------------------------------------------+       L-+-+--      
           --T-T-T-T-T-T-T-T-T-T-T-                     
    Tax withheld                                                  
                                 L-+-+-+-+-+-+-+-+-+-+-+--                     
    +-------------------------------------------------------+--------------------+
     ,      --T-T-T-T-T-T-T-T-T-T-T-     --T-
                              Tax Rate     
    Tax under the Treaty         L-+-+-+-+-+-+-+-+-+-+-+--                 L-+--
    +-------------------------------------------------+---------------------------
      ,                 --T-T-T-T-T-T-T-T-T-
    Total amount to be reimbursed                                   
    L--------------------------------------------------     L-+-+-+-+-+-+-+-+-+--

    ---------------- ---------------------------------------------------
      X X X                     
    L--L--L--L--L--L--L--L-- Fields are filled by block letters                
                             L---------------------------------------------------
     For the Claimant _______________________________________
        
       
    Double Taxation Convention
    between the Russian Federation and __________________________________________
    ----------------------+--------------------------------------------+---------
       1012DT(1997)                CLAIM                        
           /   for--
      Form 1012DT(1997)   for a refund of tax withheld in Russia on     199 
    the State Tax Service            dividends / interest                  L--
          of Russia                                                           
    +---------------------+--------------------------------------------+---------+
    1.   (Foreign entity)                                        
                               --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
                                              
                               L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
                               --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
          Name in full                                 
                               L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
                               ------------------------------------------------
                                                                   
                               L------------------------------------------------
                                ------------------  <*>          --T-
     Full residential address                                              
                               CountryL------------------ Country code <*> L-+--
    +----------------------------------------------------------------------------+
                              --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
    Identification tax number                           
                                 L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    2.  ,                          
       Authorized representative if any                                         
                                                                                
        ,    ------------------------------------------------
          ,                                                       
       Name, address, phone                                                   
                               L------------------------------------------------
    +----------------------------------------------------------------------------+
                              --T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-T-
    Identification tax number                           
                                 L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+

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