Ministry of Finance alll Bhjy Department of Zakat and Income Tax 5 lly HS 5) dale I (NS) Aa has a gS.g Aya gral) Ayal) AsLeadl) Lasse 4 pall Application for Implementation of the Effective Tax Treaty between the Kingdom of Saudi Arabia and .. To be filled out by the beneficiary: OAM ge al Ge Aes oy Beneficiary Name: Tat Pull address in the Country of Residence Hania) ay Buds atl oe Tax Identification Number in his Country: Legal Form: Types of Income: Dividends_) Interest Royalties Others, specity| I, the above mentioned beneficiary, declare that: (Ny Sel gia at + Tam the beneficial owner ofthe income on which | a.syt gal hs cl gl Saal ge gl afta Dw request the implementation ofthe tax treaty : ce + Tamaresident of under the : * treaty relevant provisions. ASG Se Gy Alga gh pila + Thaveno permanent establishment or fixed base in ti the Kingdom of Saudi Arabia to which this income | 25 1433 3tia gl 4: gual yy 4a gd gd ae ia is attributed, Jal 1a es La The work performed in the Kingdom of Saudi SNS Raga Sy pl Adal i coo, 3 a Arabia during the year ............d0es not Sal gue field fata tie SES (de constitute a permanent establishment or a fixed base Saat | according to the provisions of the treaty 7 2 7 | © This income has been or (will be) reported to the tax. | 9 gel Sey pall Abba ol} JSall Iba Ge co pac (ahi) sl ad wines pu wep TemneE Fem mat igre authorities in my country of residence. ath | Signature of beneficiary or histher legal representative Gag alias J Sal gS Date / / (ae ee | Place: 2 ean To be filled out by the foreign tax authority: Daa ON ER UE oe ats rn : , AY Ae Nagai | 1 The infra provided the above payer toe Valjean el HAN ee cee cata ol |B 2+ The above-named taxpayer is a resident Of «ss... ae = uring the year within the meaning ofthe | 2% ooh pis el al yall GC Jy ee provisions of Article (4) of the above-mentioned treaty | Renal RGEYE ce Rag 2M Gall SOY HS (ane) “Oo Where he is subject to tax. | Vp Real ay del Ug bal aha i i ‘Name: Official Seal ed ST ey] Position: | aasa| & | Signature: Date : ‘