Декларация по налогу на доходы физических лиц-нерезидентов Российской Федерации по форме 4-НДФЛ / Костромская область

Attachment No 2
to Order of the MOT of Russia
of 16.10.2003    No. BG-3-
04/540_________________

Form of TDC

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For 200 _
(Please, state the tax year)

To be submitted not later then
April 30 of the year after the
expired tax year

To the MOT of Russia Inspectorate No.

 at the place of residence/registration
(please, underline the necessary)
Information about taxpayer
TIN _____________________________________
Surname _________________________________
Name ____________________________________
Patronymic ______________________________
Type of the document, certifying the identity ____________________
Document                            Series,
code                  _________     number _______________________
Date of issue                                                                                                                 |~~|                 [~~i
of the document ___________________ Date of birth ________________
(in figures, day,                 (in figures, day,
month and year)                    month and year)
???            ???
Sex:  Male ? ?     Female ? ?
???            ???
(please, mark the necessary with x)

Residence address in the country,
which the Declarant is a resident of

Residence address or address of the
place of business in the Russian Federation
Postal code ________              Code of the region _____________
District _________________________________________________________
City _____________________________________________________________
Settlement (village, township etc.) ______________________________
Street (avenue, lane etc.) _______________________________________
House number ________________ Building(estate) number ____________
Apartment number _____________
Contact telephone number
Home: area code ____ Tel.: __________________
Office: area code _______ Tel.:___________________________________
To be filled by the taxpayer
The Declaration     with attached confirming documents
is submitted        or their copies on _______ sheets
on ____ sheets
???         ???         ???               ???
personally ? ? through ? ? by post ? ? in electronic ? ?
??? agent   ???         ??? form          ???
(please, mark the necessary with x)
I Confirm the accuracy Of the data Which I Stated in
the Declaration ____________________________________
(in figures: date, month, year)

(the taxpayer's signature)

To be filled by the tax authority
The Declaration is registered
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By No.
/tdtd class="g-nb"tabletbodytr

The Declaration            with attached confirming
is received on ??? sheets  documents or their copies
???            ???

on ??? sheets
tabletbodytr

Date of submission     ?                           ?
?????????????????????????????

(signature of the tax official)

______________________________
(in figures: date, month, year)
tabletrtd class="g-nb"
The chamber examination was
carried out on
/tdtd class="g-nb"tabletbodytr

______________________(signature of the tax official)
(in figures: date, month, year)

Seet 02

Declaration No. __________________     Form of TDC

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TIN _________________________
Surname _________________________________________ N. ____ P. _____
Income of physical persons,  who are  not  tax  residents  of  the
Russian Federation (Form 4-NDFL)
1. Income taxable at the rate of 30%
Type of activity,  which resulted in the received income,  or type
of organization - source of income.
If the source of income payment is a physical person,
please, state his/her surname, name, patronymic __________________
__________________________________________________________________
Code of     Amount of                        Taxable
income ____ income ____ Roubl _____ Kop ____ income ___ Roubl ____
Amount of
Kop. tax withheld ___ Roubl.
__________________________________________________________________
Type of activity,  which resulted in the received income,  or type
of organization - source of income.
If the source of income payment is a physical person,
please, state his/her surname, name, patronymic __________________
__________________________________________________________________
Code of     Amount of                        Taxable
income ____ income ____ Roubl _____ Kop ____ income ___ Roubl ____
Amount of
Kop. tax withheld ___ Roubl.
__________________________________________________________________
Total 1: 1.1 Total amount             1.2 Amount of tax
of income _____ Roubl ______ Kop. _____ withheld ____ Roubl ______
2. Income in relation of which special tax rates  are  applied
according to the international legislation
2.1 Name of source of income payment _____________________________
__________________________________________________________________
2.1.1 Code of income 2.1.2. Amount of income 2.1.3 Taxable income amount
Roubl. Kop ______ Roubl _____ Kop.
2.1.4 Tax  2.1.5 Amount of tax
rate         withheld
%            Roubl.
2.2 Name of source of income payment _____________________________
__________________________________________________________________
2.2.1 Code of income 2.2.2. Amount of income 2.2.3 Taxable income amount
Roubl. Kop ______ Roubl _____ Kop.
2.2.4 Tax   2.2.5 Amount of tax
rate        withheld
%           Roubl.
2.3 Name of source of income payment _____________________________
__________________________________________________________________
2.3.1 Code of income 2.3.2. Amount of income 2.3.3 Taxable income amount
Roubl. Kop ______ Roubl _____ Kop.
2.3.4 Tax  2.3.5 Amount of tax
rate        withheld
%            Roubl.
3. Amount of tax paid by the taxpayer _________________ Roubl.
4. Calculation of tax to be additionally paid (refunded)
4.1 Amount of tax to be paid
(amount of i.1.1 x 0,3 + tax calculated on income of i.2 in
accordance with Double taxation treaties. The amount of tax less
then 50 kopeks is neglected, while 50 kopeks and more are rounded
off to one rouble.) ______________________________________ Roubl.
4.2 Amount of tax withheld and paid in advance
(i.   1.2   +   i.   2.1.5   +   i.   2.2.5   +   2.3.5   +   i.3)
___________________________________________________________ Roubl.
4.3 Amount of tax to be refunded from the budget
(Deduct i.  4.1 from i.  4.2. If a value of i.4.1 is more or equal
to  value  i.  4.2,  then   i.   4.3   is   not   to   be   filled
in) _________________________________ Roubl.
4.4 Amount of tax to be paid to the budget
(Deduct i.  4.1 from i.  4.2. If a value of i.4.1 is less or equal
to  value  i.  4.2.  then   i.   4.4   is   not   to   be   filled
in) _________________________________ Roubl.
5. Calculation of advance tax payments <*>
5.1 Amount of estimated income         __________ Roubl _____ Kop.
5.2 Amount of advanced tax payment     ____________________ Roubl.
--------------------------------
<*> To be filled  in  by  enterprisers,  notaries,  and  other
persons, engaged in private practice.

The documents and                         
their copies are attached on _____ sheets.
I confirm the accuracy of data,           
which I stated                            
on this sheet page of Declaration.

(Taxpayer's signature)