• 16.06.1995 N 34 (. 07.04.2000) " " ( 05.07.1995 N 897)

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    L--L--L--L--L--L--L--L--

     Form 1012DT(1997)                                    . Page 2
    -----------------------------------------------------------------------------
    4.     Bank of recipient                               
                               --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-T-
      Number of Bank account                           
                               L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
       , :                                                            
       I declare that                                                           
       -            
         ;                                                             
       the above mentioned income is not connected with activities carried      
       in the Russian Federation;                                               
       -   ,    3 ,            
              ;                           
       on the date of accrued entered in paragraph 3, above, recipient of the   
       above income has being the beneficial owner                              
                                                                                
                              
       I hereby confirm that the information provided herewith is accurate      
                                                                                
     ------------------        ------------------------------------  
                              L------------------------------------ Occupation
                                                                              
                        ------------------------------------        
                       Stamp  L------------------------------------     Name  
                                                                              
                              ------------------------------------    
     L------------------        L------------------------------------  Signature
                                                                                
                                 --T-T-T-T-T-                              
                                 L-+-+-+-+-+--  Date                            
    +----------------------------------------------------------------------------+
    5.          
       Note of the foreign Tax authority                                        
    +----------------------------------------------------------------------------+
       ,       __________ 
                                               
       It is hereby confirmed that the claimant during _______ was a resident of
       _________________________________________________________________________
                          / name of the country                   
                /   
                                                           
       in the sence implied in the Double Taxation Convention between the USSR /
       Russian Federation and                                                   
       ________________________________________________________________________ 
                        / name of the country                     
                                                                                
              ---                       
       The claimed incomes are taxable                      
                                      L---       ( ----)
    ---------------------  --- in the country           (mark  X )
                         not taxable   of residence                   L---- 
                                    L---                                      
                          ----------------------------       
                         Stamp                                    
                                L----------------------------  Date and Place 
                                ----------------------------          
                                                                Signature   
    L---------------------        L----------------------------                 
    L-----------------------------------------------------------------------------

    ---------------- ---------------------------------------------------
      X X  X                    
    L--L--L--L--L--L--L--L-- Fields are filled by block letters                
                             L---------------------------------------------------
        
    For Claimant's foreign Tax authority ________________________________________
        
       
    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-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
    3.                                            <*> --T-T-
       Capital investment                              Currency code <*>    
                                                                         L-+-+--
             ---------------------------------------  --T-T-
    Description of investment                                             
                               L---------------------------------------  L-+-+--
    +----------------------------------------------------------------------------+
           ------------------------------------------------
                                                                     
      Name of debtor, address                                                 
                               L------------------------------------------------
    +----------------------------------------------------------------------------+
          --T-T-T-T-T-  --T-T-T-T-T-T-T-T-T-        
    Number of shares      Total par               
                    L-+-+-+-+-+--value         L-+-+-+-+-+-+-+-+-+--Date of     
    +-----------------------------------------------------------    acquisition 
      ,      --T-T-T-T-T-       --T-T-T-T-T-
    Date of accrued of dividends, interest                       
                                              L-+-+-+-+-+--       L-+-+-+-+-+--
    +------------------------------------+----------------------+----------------+
          --T-T-T-T-T-       --T-              
                        A                          D                 
    Dividends per share   L-+-+-+-+-+--  Interest rate (%)  L-+--              
    +------------------------------------+---------------------------------------+
      -                                                 
       --T-T-T-T-T-T-T-T-     --T-T-T-T-T-T-T-T-
    Dividends from  B              E          
    subsidiary       L-+-+-+-+-+-+-+-+-- Interest on        L-+-+-+-+-+-+-+-+--
    +------------------------------------+ government bonds                      
                             +---------------------------------------+
       --T-T-T-T-T-T-T-T-      --T-T-T-T-T-T-T-T-
    Dividends from  C                           F          
    other companies  L-+-+-+-+-+-+-+-+-- Other interest     L-+-+-+-+-+-+-+-+--
    +------------------------------------+---------------------------------------+
          --T-T-T-T-T-T-T-T-            --T-
    Amount of Tax withheld                            Tax Rate     
                                L-+-+-+-+-+-+-+-+--                        L-+--
    +----------------------------------------------------------------------------+
                     --T-T-T-T-T-T-T-T-            --T-
                                           
    Amount of Tax               L-+-+-+-+-+-+-+-+--         Tax rate under L-+--
    under the Treaty                                          the Treaty        
    +---------------------------------------------+-------------------------------
      ,               --T-T-T-T-T-T-T-T-T-T-
    Total amount to be reimbursed                                  
                                                        L-+-+-+-+-+-+-+-+-+-+--
    L----------------------------------------------

          _____   Enclosures on _____ pages

        --------------------------------
        <*>      "BIC directory".  By reference book "BIC
    directory".

    ----------------
      X     
    L--L--L--L--L--L--L--L--

     Form 1012DT(1997)                                    . Page 2
    -----------------------------------------------------------------------------
    4.     Bank of recipient                               
                               --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-T-
      Number of Bank account                           
                               L-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--
    +----------------------------------------------------------------------------+
       , :                                                            
       I declare that                                                           
       -            
         ;                                                             
       the above mentioned income is not connected with activities carried      
       in the Russian Federation                                                
       -   ,    3 ,            
              ;                           
       on the date of accrued entered in paragraph 3, above, recipient of the   
       above income has being the beneficial owner                              
                                                                                
                              
       I hereby confirm that the information provided herewith is accurate      
                                                                                
     ------------------        ------------------------------------  
                              L------------------------------------ Occupation
                                                                              
                        ------------------------------------        
                       Stamp  L------------------------------------     Name  
                                                                              
                              ------------------------------------    
     L------------------        L------------------------------------  Signature
                                                                                
                                 --T-T-T-T-T-                              
                                 L-+-+-+-+-+--  Date                            
    +----------------------------------------------------------------------------+
    5.          
       Note of the foreign Tax authority                                        
    +----------------------------------------------------------------------------+
       ,       __________ 
                                               
       It is hereby confirmed that the claimant during _______ was a resident of
       _________________________________________________________________________
                          / name of the country                   
                /   
                                                           
       in the sense implied in the Double Taxation Convention between the USSR /
       Russian Federation and                                                   
       ________________________________________________________________________ 
                        / name of the country                     
                                                                                
              ---                       
       The claimed incomes are taxable                      
                                      L---       ( ----)
    ---------------------  --- in the country           (mark  X )
                         not taxable   of residence                   L---- 
                                    L---                                      
                          ----------------------------       
                         Stamp                                    
                                L----------------------------  Date and Place 
                                ----------------------------          
                                                                Signature   
    L---------------------        L----------------------------                 
    L-----------------------------------------------------------------------------

    ---------------- ---------------------------------------------------
       XXX X                    
    L--L--L--L--L--L--L--L-- Fields are filled by block letters                
                             L---------------------------------------------------
                                                    --T-T-T-
    To the State Tax Office ________________________________________  N     
                                                                        L-+-+-+--
        
       
    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-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+--

    : | .1 | .2 | .3 | .4 | .5 | .6 | .7 | .8 | .9 | .10 | .11 | .12 | .13 | .14 | .15 | .16 | .17 | .18 | .19 | .20 |


 

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