Form No: 04/CNV-TNCN

(Issued under the Circular of the

SOCIALIST REPUBLIC OF VIETNAM Ministry of Finance No: 92/2015/TT-
Independence - Freedom - Happiness BTC on 15 June 2015)

DECLARATION OF PERSONAL INCOME TAX

(Applicable to residents with income from transferring capital & securities declaring directly to tax authorities)

[01] Tax period: dated………………………………

[02] First time: [03] Addition to the time of:

I. THE INFORMATION OF INDIVIDUALS TRANSFERRING CAPITAL & SECURITIES DECLARING

DIRECTLY TO TAX AUTHORITIES
[04] Name of the tax payer:……………..……………………....................................

[05] Tax code:

[06] Address: ………………………………...………...…………….…………………

[07] District: ........................ [08] Province: ................................................

[09] Phone:……..............…..[10] Fax:….….…….... [11] Email:…..…...………..

[12] Name of the organizational declarant (if any):……………………….......................

[13] Tax code:

[14] Address: ……………………..………………………………………………….
[15] District: ................... [16] Province: ................................................
[17] Phone: ..................... [18] Fax: .......................... [19] Email: ......................
[20] Name of the tax agent (if any):………………………………..................................

[21] Tax code:

[22] Address: …………………………………………………………………………...

[23] District: ................... …..[24] Province: ...............................................
[25] Phone: .................... .…. [26] Fax: ....................... [27] Email: .......................
[28] Tax agent contract: No............................................Dated:....................................
[29] Capital transfer contract: No.….………...…..Dated:.………………………...
[30] Enterprise Registration Certificate No.............................Dated:.…………………………………
Licensing authority: .............................................................Date of issuance:.............................
II. THE INFORMATION OF INDIVIDUALS RECEIVING CAPITAL & SECURITIES TRANSFER
DECLARING DIRECTLY TO TAX AUTHORITIES
[31] Full name: ...............................................................................................................................................

[32] Tax code:

[33] National ID Card/ Passport (in case there is no tax code): ......................................................................
[34] Address: ..................................................................................................................................................
[35] District: .....................[36] Province: ....................................................
[37] Phone:………………….[38] Fax:……...………....[39] Email: ..................................................................

1
 III. TAX CALCULATION DETAILS

Currency: Vietnam Dong

Criteria
No. Criteria Amount of money
Code
I Income from capital transfer
1 Value of the transfer [40]
2 Cost of capital transferred [41]
3 Expense of the transfer [42]

4 Assessable income from capital transfer [43]=[40]-[41]-[42] [43]

5 Tax payable [44]
Tax exemption or reduction amount under the Agreement on
6 [45]
avoidance of double taxation

7 The remaining tax payable [46]=[44]-[45] [46]

II Income from securities transfer which is declared directly

1 Value of the transfer [47]
2 Tax payable [48]
Tax exemption or reduction amount under the Agreement on
3 [49]
avoidance of double taxation
4 The remaining tax payable [50]=[48]-[49] [50]

(Note: In case individuals are entitled to tax exemption or reduction under the Agreement on avoidance of
double taxation, it is requested to submit a dossier of notification of tax exemption or reduction under the
Agreement)
I declare that the aforesaid is correct and take responsibility for the declared data./.

TAX AGENT …….…, dated………………………

Full name: …………………..
TAX PAYER or
Practice Certificate No.:........
LEGAL REPRESENTATIVE OF THE TAX PAYER
Sign; write full name, position and seal (if any)