(, , , , , )

IV.

/

( )

V.

Annex on Pages

Income paid if not withheld

Reduced tax withheld at source

In accordance with Georgian Tax Code

Identification number of tax agent

Amount withheld

II.

/, Title/Name, Surname

Address (street, no., town, province, postal code, if any)

, /

N 1

Form N 1

I. Information about tax agent

Tax agent information on exemption or reduction of tax withheld at source on income paid to non-resident

III.

, . .

I certify that the information is correct and complete. I undertake to inform the tax authority if there is any change to the given information.

.

Certificate of residence of the recipient of income must be issued by the competent authority of that country and simultaneously presented together with this form by tax agent.

In accordnace

with Internation

al Agreement

Name, Surname/Title of the income

recipient

(, , )

Date (DD-MM-YYYY)Signature and stamp (if any)

Date of payment

Identification Number of the

income recepient

Withholding tax rate

Country of residence

Type of income by code

Contract number / date (if applicable)

( )

N 2 /

Form N 2 Declaration of a Non-Resident on taxes paid/withheld in Georgia and claim for their repayment

Identification of the Recipient of Income1. , / 2. Identification number of the recipient of income

Form N 2 Declaration of a Non-Resident on taxes paid/withheld in Georgia and claim for their repayment IPart I

1. , / 2. Identification number of the recipient of income

( ) In foreign country (if any) In Georgia

Name, Surname/Title

3. (, , ) ( )Date (DD-MM-YYYY) and place of birth (in the case of individual)

4. (, , , , , ) 4. (, , , , , ) Address (street, no., town, province, postal code, if any)

5. ( )5. ( )Mailing adress (if different from above)

6.

Bank title, code ("e.g" SWIFT, IBAN, etc.) and account no. of the bank to which the income is transferred (if available) , (: SWIFT, IBAN ..) , ( )Bank title, code ("e.g" SWIFT, IBAN, etc.) and account no. of the bank to which the income is transferred (if available)

7.

The State of residence

Place of incorporation Place of effective management Other

8. , 8. , If the recipient of income has a permanent establishment in Georgia, indicate the name and the identification number

Part II Payment of income

II

9.

Part II Payment of income

Codes of income: 01. Interest; 02. Dividends; 03. Capital gains; 04. Royalties; 05. Compensation for independent personal services; 06. Compensation for employment; 07. Other income Compensation for independent personal services; 06. Compensation for employment; 07. Other income

) )

Indicate in the field a) the amount withheld b) the amount to be repaid

, //

/

( )

Contract number/date(if applicable)

Date of payment Name, Surname/Title of payer

Amount of tax withheld/to be repaid

Taxpayer identification numberCode

Income before tax

( )

(if applicable)Date of payment Name, Surname/Title of payer

repaidTaxpayer identification numberCode Income before tax

a)

b)b)

a)

b)b)

a)

b)

Confirmation of a tax agent IIIPart III

b)

10. , -2 . hereby certify that information given in part II of the declaration is correct and the tax of a non-resident has been withheld at source.

(, , )

Date (DD-MM-YYYY) ( )

Signature and stamp (if any) ,

Tax Agent Name, Surname

Date (DD-MM-YYYY) Signature and stamp (if any) Tax Agent Name, Surname

IV Part IV Certificate

11. , .

I hereby certify that I am a beneficial owner with respect to the income to which this form relates.

12. I claim repayment of

13. , (: SWIFT, IBAN ..) , / /

GEL.

13. , (: SWIFT, IBAN ..) , / /

Bank title, code ("e.g" SWIFT, IBAN, etc.) and account number to which taxes withheld in Georgia should be transferred

14. . .

The information is correct and complete. I undertake to inform the tax authority if there is any change to the given information.

( )

The information is correct and complete. I undertake to inform the tax authority if there is any change to the given information.

(, , ) ( ) (, , )

Date (DD-MM-YYYY) Capacity in which acting Signature and stamp (if any)

.

Certificate of residence of the recipient of income must be issues by the competent authority of that country and simultaneously presented together with this form by tax agent.

.

tax agent.

PagesAnnex on

I

N 3 /

Form N 3 Request of a Non-Resident for Issuing Certificate of Taxes Paid in Georgia

1. , /

I Part I To be filled by applicant

Identification of applicant1. , / Name, Surname/Title

2. ( ) Georgian taxpayer identification number (if any)

3. (, , , , , ) Address (street, no., town, province, postal code, if any)

4. Country of residence

II Part II

Payment of income5.

,/ (

)

Part II

Payment of income

Type of income

Date of payment Name, Surname/Title of tax agent (identification number, if any)

Income before tax Amount of tax withheldRate of tax withheld

III

IIIPart III

Capital situated in Georgia

6.

Type of capital Address where situated Value Amount of tax paid

IV Part IV

Certificate 7. . 7. . .

The information is correct and complete.I undertake to inform the tax authorities if there is any change to the given information.

Date (DD-MM-YYYY)Signature and stamp (if any)

( )

Capacity in which acting

V.

(, , )

Certificate of the tax authority of Georgia

V. Part V. To be filled by tax authority

8. Tax authority

I certify that paid taxes

Certificate of the tax authority of Georgia

,

on income

I certify that paid taxes

GEL.

on capital

GEL. Ofcial

stamp of tax authority

Date (DD-MM-YYYY) (, , )

Signature and stamp (if any)

( )

N 4 Form N 4 Application for Certificate of Residence

I Part I To be filled by applicant

1. , / Name, Surname/Title

Identification of applicant Part I To be filled by applicant

Name, Surname/Title

2. ( ) Georgian taxpayer identification number (if any)

3. (, , , , , ) Address (street, no., town, province, postal code, if any)

Georgian taxpayer identification number (if any)

Address (street, no., town, province, postal code, if any)

4. 4.

(in the case of individual)Title of personal identification document

( )

Date of issue /date of expiry /

5. : Georgia is:

Identification number

Place of incorporation Place of effective management Other

6. 6.

The application is made for the purpose of claiming the Certificate of Residence for year

( )

Signature and stamp (if any)

(, , )

Date (DD-MM-YYYY)Signature and stamp (if any) Date (DD-MM-YYYY)

II. Part II. To be filled by tax authority

Certificate of Residence For Year

7. , / .

,

7. , / .I certify that the person/entity named above is/was resident of Georgia for tax purposes.

Name, Surname of tax official

Position

,

Position

Tax authority

Address of tax authority

Ofcial

stamp of tax authoritystamp of tax authority

Date (DD-MM-YYYY) (, , )

Signature