## Objava Priloga uz Pravilnik o porezu na dohodak

### NN 1/2001 (5.1.2001.), Objava Priloga uz Pravilnik o porezu na dohodak

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31

Uz Pravilnik o porezu na dohodak objav­ljenom u »Narodnim novinama«,
broj 132 od 29. prosinca 2000. godine, greškom nije objav­ljen prilog
obrazac-ostali dohodak i prilog obrazac-licence, pa se uz citirani Pravilnik
objav­ljuje

## PRILOG

### OBRAZAC-OSTALI DOHODAK OBRAZAC-LICENCE UZ PRAVILNIK O POREZU NA DOHODAK

Uz Pravilnik o porezu na dohodak objav­ljuje se obrazac-ostali dohodak
primjerak 1 do 4 i Upute za popu­njava­nje: Ostali dohodak, te obrazac-licence
1 do 4 i Upute za popu­njava­nje: Licence.

Urbroj: 50501-01-7
Zagreb, 4. siječ­nja 2001.

Glavna urednica
»Narodnih novina«
**S­nježana Bagić,** v. r.

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OBRAZAC –
OSTALI DOHODAK
FORM  – OTHER INCOME

PRIMJERAK
1
- za podnositelja zahtjeva -
*COPY 1
- for the claimant -*

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# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX
ADMINISTRATION***

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**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA NA

NAKNADE ZA DJELATNOST OBAVLJENU U REPUBLICI HRVATSKOJ, PREMA UGOVORU O

IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine –
Međunarodni ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR REMUNERATION FOR INDEPENDENT

### PERSONAL SERVICES RENDERED IN THE REPUBLIC OF CROATIA UNDER THE AGREEMENT  FOR THE AVOIDANCE

### OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 36. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit (“Narodna novine”, broj 127/00.) - *The data to be given in this application are requested under Article 36 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

## I.      PODACI O ISPLATITELJU– *INFORMATION ON THE PAYER:*

Ime i prezime / naziv tvrtke  – *Full name / business name*:
.................................................................................................................

        Pravni oblik – *Legal form*:
......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
...............................................Grad – *City:*
................................................................................….

                Država – *State:*
..............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - primatelju NAKNADE – *INFORMATION
ON THE CLAIMANT – recipient of the REMUNERATION:***

Ime i prezime / naziv tvrtke – *Full name / business name: ......................................*
...........................................................................

        (umjetničko ime, ako ga ima – *artistic name, if there is any):
................................................................................................................*

        Pravni oblik – *Legal form*:
......................................................................................................................................................................

        Broj – *Number:*
.......................................................................................................................................................................................

        Prebivalište / sjedište – *Address:* .......................................................................................................................................…………….

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
................................................Grad – *City:*
................................................................................….

                Država – *State:*
..............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

**if !supportEmptyParas endif**

**III.    VRSTA
DJELATNOSTI (umjetničke, književne i druge djelatnosti) – *TYPE OF ACTIVITY (for example artistic, literary and other activities)*:**
...................................................................................................................................................…………………………….

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**IV.**endif**TRAJANJE DJELATNOSTI (priredba/e je/su održana/e u
razdoblju) – *THE DURATION OF THE ACTIVITY
(the performance/s  was/were held during
the period):***

Početak – *Beginning:* .............................................................................................................................................................................

        Završetak – *End:*
....................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**V.**endif**PODACI O NAKNADI – *INFORMATION
ABOUT THE REMUNERATION:***

a)     ukupna
naknada – *total amount of the
remuneration: .*..................................................................................................................

        b)     postotak
porezno priznatih troškova – *the
percentage of the deductible costs*:
............................................................................

        c)     (a)-(b)=porezna
osnovica – *(a)-(b)=tax base:*
................................................................................................................................

        d)     iznos
poreza – *the amount of tax*:
..................................................................................................................................................

        e)     datum
uplate – *date of payment:* ....................................................................................................................................................

**if !supportEmptyParas endif**

**VI.   PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***...............................................………………..

        ...............................................................................................................................................................................................................

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if !supportEmptyParas endif

**VII.  NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa – *To the account number:
.............................................................................................................................................*

        Kod (banka) – *With the (bank): ..............................................................................................................................................................*

        Otvorenog na ime – *Opened in the name of:
........................................................................................................................................*

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if !supportEmptyParas endif

**VIII. IZJAVA
PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE
CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions:*

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak
u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren
kroz djelatnost registriranu u Republici Hrvatskoj – *He did not derive income, as defined in the mentioned Agreement for the
avoidance of double taxation, through the activity registered in the Republic
of Croatia,*

*3.* Svi su prihodi od priredbe
/ niza priredaba ili sličnih poslova u cijelosti prijavljeni – *The total amount of all of the items of
income from the performance / number of performances is declared.*

Poznato mi je da Porezna uprava Republike
Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja zahtjeva davati
podatke o sadržaju ovog zahtjeva – *I am
aware of the fact that the Croatian Tax Administration can disclose the
information given in this Application to the tax authorities in the country of
residence of the claimant.*

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                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and
date*                                                                                   Potpis - *Signature*

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**IX.    POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA
ZAHTJEVA – *CERTIFICATE OF TAX AUTHORITY
OF CLAIMANT´S COUNTRY OF RESIDENCE:***

Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora
o izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i
.................................... – *The
claimant is the resident of ................................... under Article
.......... of the Agreement for the avoidance of double taxation between the
Republic of Croatia and ....................................*

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        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

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##

PRIMJERAK
2
- za isplatitelja dohotka -
COPY 2
- for the payer of the income -

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# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX
ADMINISTRATION***

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**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA NA

NAKNADE ZA DJELATNOST OBAVLJENU U REPUBLICI HRVATSKOJ, PREMA UGOVORU O

IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine –
Međunarodni ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR REMUNERATION FOR INDEPENDENT

### PERSONAL SERVICES RENDERED IN THE REPUBLIC OF CROATIA UNDER THE AGREEMENT  FOR THE AVOIDANCE

### OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 36. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit (“Narodna novine”, broj 127/00.) - *The data to be given in this application are requested under Article 36 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

if !supportEmptyParas endif

**if !supportEmptyParas endif**

## I.      PODACI O ISPLATITELJU– *INFORMATION ON THE PAYER:*

Ime i prezime / naziv tvrtke– *Full name / business name*: ....................................................................................................................

        Pravni oblik – *Legal form*:
......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Prebivalište / sjedište – *Address:* ...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
......................................Grad – *City:*
..................................................................................

                Država – *State:*
..............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - primatelju NAKNADE – *INFORMATION
ON THE CLAIMANT – recipient of the REMUNERATION:***

Ime i prezime / naziv tvrtke – *Full name / business name:
...............................................*
....................................................................

        (umjetničko ime, ako ga ima – *artistic name, if there is any):
................................................................................................................*

        Pravni oblik – *Legal form*: ......................................................................................................................................................................

        Broj – *Number:* .......................................................................................................................................................................................

        Prebivalište / sjedište – *Address:*
..........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
................................................Grad – *City:*
................................................................................….

                Država – *State:* ..............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

**if !supportEmptyParas endif**

**III.    VRSTA
DJELATNOSTI (umjetničke, književne i druge djelatnosti) – *TYPE OF ACTIVITY ( for example artistic, literary and other activities)*:**
......................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**IV.**endif**TRAJANJE DJELATNOSTI (priredba/e je/su održana/e u
razdoblju) – *THE DURATION OF THE ACTIVITY
(the performance/s  was/were held during
the period):***

Početak – *Beginning:* .............................................................................................................................................................................

        Završetak – *End:*
....................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**V.**endif**PODACI O NAKNADI – *INFORMATION
ABOUT THE REMUNERATION:***

a)     ukupna
naknada – *total amount of the
remuneration: .*..................................................................................................................

        b)     postotak
porezno priznatih troškova – *the
percentage of the deductible costs*:
............................................................................

        c)     (a)-(b)=porezna
osnovica – *(a)-(b)=tax base:*
................................................................................................................................

        d)     iznos
poreza – *the amount of tax*:
..................................................................................................................................................

        e)     datum
uplate – *date of payment:*
....................................................................................................................................................

**if !supportEmptyParas endif**

**VI.   PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***......................................................................

        ...............................................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**VII.  NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa –*To the account number: ...............................................................................................*

        Kod (banka) – *With the (bank):
..............................................................................................................................................................*

        Otvorenog  na ime – *Opened in the name
of:
.......................................................................................................................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

**VIII. IZJAVA
PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE
CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions:*

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak
u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren
kroz djelatnost registriranu u Republici Hrvatskoj – *He did not derive income, as defined in the mentioned Agreement for the
avoidance of  double taxation, through
the activity registered in the Republic of Croatia,*

*3.* Svi su prihodi od priredbe
/ niza priredaba ili sličnih poslova u cijelosti prijavljeni – *The total amount of all of the items of
income from the performance / number of performances is declared.*

Poznato mi je da Porezna uprava Republike
Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja zahtjeva davati
podatke o sadržaju ovog zahtjeva – *I am
aware of the fact that the Croatian Tax Administration can disclose the
information given in this Application to the tax authorities in the country of
residence of the claimant.*

if !supportEmptyParas endif

                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and date*                                                                                    Potpis - *Signature*

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**IX.    POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA
ZAHTJEVA – *CERTIFICATE OF TAX AUTHORITY
OF CLAIMANT´S COUNTRY OF RESIDENCE:***

Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora
o izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i
.................................... – *The
claimant is the resident of ................................... under Article
.......... of the Agreement for the avoidance of double taxation between the
Republic of Croatia and ....................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

if !supportEmptyParas endif

if !supportEmptyParas endif

PRIMJERAK
3
- za Poreznu upravu Republike Hrvatske -
COPY 3
- for the Tax Administration of the Republic of Croatia -

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX
ADMINISTRATION***

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA NA

NAKNADE ZA DJELATNOST OBAVLJENU U REPUBLICI HRVATSKOJ, PREMA UGOVORU O

IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine –
Međunarodni ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR REMUNERATION FOR INDEPENDENT

### PERSONAL SERVICES RENDERED IN THE REPUBLIC OF CROATIA UNDER THE AGREEMENT  FOR THE AVOIDANCE

### OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 36. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit (“Narodna novine”, broj 127/00.) - *The data to be given in this application are requested under Article 36 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

## I.      PODACI O ISPLATITELJU– *INFORMATION ON THE PAYER:*

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik – *Legal form*:
......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
...............................................Grad – *City:*
................................................................................…..

                Država – *State:*
..............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - primatelju NAKNADE – *INFORMATION
ON THE CLAIMANT – recipient of the REMUNERATION:***

Ime i prezime / naziv tvrtke – *Full name / business name:
...............................................*
....................................................................

        (umjetničko ime, ako ga ima – *artistic name, if there is any):
................................................................................................................*

        Pravni oblik – *Legal form*:
......................................................................................................................................................................

        Broj – *Number:*
.......................................................................................................................................................................................

        Prebivalište / sjedište – *Address:* ...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
..................................................Grad – *City:*
..................................................................................

                Država – *State:*
..............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

**if !supportEmptyParas endif**

**III.    VRSTA
DJELATNOSTI (umjetničke, književne i druge djelatnosti) – *TYPE OF ACTIVITY (for example artistic, literary and other activities)*:**
...........................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**IV.**endif**TRAJANJE DJELATNOSTI (priredba/e je/su održana/e u
razdoblju) – *THE DURATION OF THE ACTIVITY
(the performance/s  was/were held during
the period):***

Početak – *Beginning:*
.............................................................................................................................................................................

        Završetak – *End:* ....................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**V.**endif**PODACI O NAKNADI – *INFORMATION
ABOUT THE REMUNERATION:***

a)     ukupna
naknada – *total amount of the
remuneration: .*..................................................................................................................

        b)     postotak
porezno priznatih troškova – *the
percentage of the deductible costs*: ............................................................................

        c)     (a)-(b)=porezna
osnovica – *(a)-(b)=tax base:*
................................................................................................................................

        d)     iznos
poreza – *the amount of tax*:
..................................................................................................................................................

        e)     datum
uplate – *date of payment:*
....................................................................................................................................................

**if !supportEmptyParas endif**

**VI.   PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***......................................................................

        ...............................................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**VII.  NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa – *To the account number:
...................................................................................................................................……..*

        Kod (banka) – *With the (bank):
..............................................................................................................................................................*

        Otvorenog na ime – *Opened in the name of:
........................................................................................................................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

**VIII. IZJAVA
PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE
CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions:*

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak
u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren
kroz djelatnost registriranu u Republici Hrvatskoj – *He did not derive income, as defined in the mentioned Agreement for the
avoidance of  double taxation, through
the activity registered in the Republic of Croatia,*

*3.* Svi su prihodi od priredbe
/ niza priredaba ili sličnih poslova u cijelosti prijavljeni – *The total amount of all of the items of
income from the performance / number of performances is declared.*

Poznato mi je da Porezna uprava Republike
Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja zahtjeva davati
podatke o sadržaju ovog zahtjeva – *I am
aware of the fact that the Croatian Tax Administration can disclose the
information given in this Application to the tax authorities in the country of residence
of the claimant.*

if !supportEmptyParas endif

                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and date*                                                                                    Potpis - *Signature*

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**IX.    POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA
ZAHTJEVA – *CERTIFICATE OF TAX AUTHORITY
OF CLAIMANT´S COUNTRY OF RESIDENCE:***

Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora
o izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i ....................................
– *The claimant is the resident of
................................... under Article .......... of the Agreement
for the avoidance of double taxation between the Republic of Croatia and
....................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

## if !supportEmptyParas endif

if !supportEmptyParas endif

**VIII. NAPOMENE POREZNE
UPRAVE REPUBLIKE HRVATSKE (ako ih ima) – CROATIAN TAX AUTHORITIES REMARKS (if
any)**

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

PRIMJERAK
4
- za inozemno porezno tijelo -
COPY 4
- for the foreign tax authotity -

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX
ADMINISTRATION***

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA NA

NAKNADE ZA DJELATNOST OBAVLJENU U REPUBLICI HRVATSKOJ, PREMA UGOVORU O

IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine –
Međunarodni ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR REMUNERATION FOR INDEPENDENT

### PERSONAL SERVICES RENDERED IN THE REPUBLIC OF CROATIA UNDER THE AGREEMENT  FOR THE AVOIDANCE

### OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 36. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit (“Narodna novine”, broj 127/00.) - *The data to be given in this application are requested under Article 36 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

## I.      PODACI O ISPLATITELJU– *INFORMATION ON THE PAYER:*

Ime i prezime / naziv tvrtke  – *Full name / business name*:
..................................................................................................................

        Pravni oblik – *Legal form*:
......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
..................................................Grad – *City:*
..................................................................................

                Država – *State:*
..............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - primatelju NAKNADE – *INFORMATION
ON THE CLAIMANT – recipient of the REMUNERATION:***

Ime i prezime / naziv tvrtke – *Full name / business name:
...............................................*
..................................................................

        (umjetničko ime, ako ga ima – *artistic name, if there is any):
................................................................................................................*

        Pravni oblik – *Legal form*: ......................................................................................................................................................................

        Broj – *Number:*
.......................................................................................................................................................................................

        Prebivalište – *Address:*
.....................................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
...............................................Grad – *City:*
..................................................................................

                Država – *State:*
..............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:* ...........................................................................................................................................................

**if !supportEmptyParas endif**

**III.    VRSTA
DJELATNOSTI (umjetničke, književne i druge djelatnosti) – *TYPE OF ACTIVITY (for example artistic, literary and other activities)*:**
.............................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**IV.**endif**TRAJANJE DJELATNOSTI (priredba/e je/su održana/e u
razdoblju) – *THE DURATION OF THE ACTIVITY
(the performance/s  was/were held during
the period):***

Početak – *Beginning:*
.............................................................................................................................................................................

        Završetak – *End:*
....................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportLists**V.**endif**PODACI O NAKNADI – *INFORMATION
ABOUT THE REMUNERATION:***

a)     ukupna
naknada – *total amount of the
remuneration: .*..................................................................................................................

        b)     postotak
porezno priznatih troškova – *the percentage
of the deductible costs*:
............................................................................

        c)     (a)-(b)=porezna
osnovica – *(a)-(b)=tax base:*
................................................................................................................................

        d)     iznos
poreza – *the amount of tax*:
..................................................................................................................................................

        e)     datum
uplate – *date of payment:* ....................................................................................................................................................

**if !supportEmptyParas endif**

**VI.   PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***......................................................................

        ...............................................................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**VII.  NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa –*To the account number:
...............................................................................................................................*

        Kod (banka) – *With the (bank):
..............................................................................................................................................................*

        Otvorenog na ime – *Opened in the name of:
........................................................................................................................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

**VIII. IZJAVA
PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE
CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions:*

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak
u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren
kroz djelatnost registriranu u Republici Hrvatskoj – *He did not derive income, as defined in the mentioned Agreement for the
avoidance of double taxation, through the activity registered in the Republic
of Croatia,*

*3.* Svi su prihodi od priredbe
/ niza priredaba ili sličnih poslova u cijelosti prijavljeni – *The total amount of all of the items of
income from the performance / number of performances is declared.*

Poznato mi je da Porezna uprava Republike
Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja zahtjeva davati
podatke o sadržaju ovog zahtjeva – *I am
aware of the fact that the Croatian Tax Administration can disclose the
information given in this Application to the tax authorities in the country of
residence of the claimant.*

if !supportEmptyParas endif

                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and date*                                                                                    Potpis - *Signature*

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**IX.    POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA ZAHTJEVA
– *CERTIFICATE OF TAX AUTHORITY OF
CLAIMANT´S COUNTRY OF RESIDENCE:***

Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora
o izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i ....................................
– *The claimant is the resident of
................................... under Article .......... of the Agreement
for the avoidance of double taxation between the Republic of Croatia and
....................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

## if !supportEmptyParas endif

if !supportEmptyParas endif

*UPUTA ZA POPUNJAVANJE: **OSTALI DOHODAK***

***if !supportEmptyParas endif***

if !supportLists1.
endifOvaj obrazac
podnosi se radi umanjenja porezne obveze, izuzimanja od poreza ili povrata više
plaćenog poreza za naknadu za obavljenu djelatnost osobi koja ima prebivalište,
uobičajeno boravište ili sjedište (rezidentu) u državi s kojom je Republika
Hrvatska sklopila Ugovor o izbjegavanju dvostrukog oporezivanja.

if !supportEmptyParas endif

if !supportLists2.
endifObrazac se sastoji od četiri primjerka. Prvi je
primjerak za podnositelja zahtjeva, drugi za isplatitelja, treći za Poreznu
upravu Ministarstva financija Republike Hrvatske, a četvrti za inozemno porezno
tijelo. Točke II, VI, VII i VIII popunjava podnositelj zahtjeva, točke I, III,
IV i V popunjava isplatitelj, a točku IX popunjava inozemno porezno tijelo.
Popunjeni i potpisani primjerci obrasca predaju se inozemnim poreznim tijelima
zemlje koje je primatelj rezident. Inozemna porezna tijela će provesti potrebnu
kontrolu, ovjeriti predočeni obrazac i zadržati svoj primjerak, a podnositelju
zahtjeva vratiti preostala tri primjerka (za podnositelja zahtjeva, isplatitelja
i Poreznu upravu Ministarstva financija Republike Hrvatske).

if !supportEmptyParas endif

if !supportLists3.
endifZa svakog isplatitelja i za svaku isplatu podnosi se
poseban zahtjev.

if !supportEmptyParas endif

if !supportLists4.
endifZahtjev za umanjenje porezne obveze, izuzimanje od
poreza ili povrat više plaćenog poreza podnosi se Ministarstvu financija
Republike Hrvatske, Poreznoj upravi, Područnom uredu Zagreb, Avenija Dubrovnik
32, najkasnije u roku od tri godine od isteka kalendarske godine u kojoj je
isplata izvršena.

if !supportEmptyParas endif

*INSTRUCTIONS FOR FILLING IN THE FORM: **OTHER INCOME***

***if !supportEmptyParas endif***

if !supportLists1.
endifThis form is submitted for tax relief, tax exemption or
tax refund for remuneration to a resident of the country with which the
Republic of Croatia entered into Agreement for the Avoidance of Double
Taxation.

if !supportEmptyParas endif

if !supportLists2.
endifThe form consists of four copies. The first copy is for
the claimant, the second for the payer of the income, the third copy for the
Tax Administration of the Republic of Croatia, and the forth copy for the
foreign tax authority. Items II, VI, VII , and VIII are to be filled in by the
claimant, items I, III, IV and V by the payer of the income, and the item IX by
the foreign tax authority. The filled in and signed copies of the form are
submitted to the tax authorities of the country in which the recipient is
resident. Foreign tax authorities shall carry out the required control, certify
a submitted form, and retain their own copy, and return the three remaining
copies to the claimant (for the claimant, payer of the income, and the Tax
Administration of the Republic of Croatia).

if !supportEmptyParas endif

if !supportLists3.
endifFor each payer and for each payment a separate claim is
made.

if !supportEmptyParas endif

if !supportLists4.
endifApplication for tax relief, tax exemption or tax refund
is submitted to the Ministry of finance of the Republic of Croatia, Tax
Administration, Zagreb office, Avenija Dubrovnik 32, at latest within 3 years
as of expiry of the calendar year in which the payment is effected.

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

OBRAZAC-LICENCE
FORM - ROYALTIES

PRIMJERAK
1

-
za podnositelja zahtjeva-

*COPY 1*

*- for the claimant -*

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX
ADMINISTRATION***

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA

NA LICENCE I SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine –
Međunarodni ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR ROYALTIES UNDER

### THE AGREEMENT  FOR THE AVOIDANCE OF DOUBLE TAXATION BETWEEN

### THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 23. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 23 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

## I.              PODACI O StjecateljU licence – *INFORMATION ON THE LICENSEE:*

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik - *Legal form*: .......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Zanimanje / djelatnost – *Occupation:*
.....................................................................................................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:* …………………………………….Grad – *City:* .............…………………………………………………

                Država – *State:* ...............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - DavateljU licence – *INFORMATION ON THE CLAIMANT – LICENSor:***

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik - *Legal form*:
.......................................................................................................................................................................

        Broj – *Number:*
.......................................................................................................................................................................................

        Zanimanje / djelatnost – *Occupation:*

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
......................................Grad – *City:*
................................................................................…………

                Država – *State:* ...............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

**III.    Predmet
ugovora o licenci – *SUBJECT MATTER OF
LICENCE:***

**if !supportEmptyParas endif**

**3.1. Prava
intelektualnog vlasništva – *Intellectual
property rights***

3.1.1. Vrste prava intelektualnog vlasništva – *Form of intellectual property right:*

........................................................................................................................................................................................................

                ........................................................................................................................................................................................................

3.1.2. Registracija prava intelektualnog vlasništva – *Registration of intellectual property right:*

                Država registracije – *Country of registration:*
.................................................................................................................................

                Broj registracije – *Registration number*:
.........................................................................................................................................

Datum registracije – *Date
of registration:*
.......................................................................................................................................

        3.1.3. Nositelj
prava intelektualnog vlasništva prema registru – *Registered owner  of
intellectual property  right*:

                Ime i prezime / naziv tvrtke – *Full name / business name:*
............................................................................................................

                Pravni oblik - *Legal form*:
...............................................................................................................................................................

                Zanimanje / djelatnost – *Occupation:*
.............................................................................................................................................

                Prebivalište / sjedište – *Address:*
...................................................................................................................................................

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
.................................... Grad – *City:*
..........................................................................……….

                        Država – *State:*
.....................................................................................................................................................................

**3.2. Prava na korištenje pokretnina** (između
ostalog leasing-ugovori) – *Right to use
movable property (under a leasing or
another agreement)*

3.2.1. Vrste pokretnina – *Type of movable
property:.............................................................................................................................*

                ........................................................................................................................................................................................................

**3.3 Autorska
prava** (prava koja ne
spadaju pod točku 3.1) – *Copyrights
(other than those under paragraph 3.1)*

3.3.1. Vrste autorskog prava – *Form of copyright*:
.................................................................................................................................

3.3.2. Naziv zaštićenog djela – *Title of protected work:
........................................................................................................................*

3.3.3. Autor - *Author*

        Ime – *Name:*
...................................................................................................................................................................................

Prezime – *Surname:*
.......................................................................................................................................................................

                Prebivalište / sjedište – *Address:*

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
..........................................Grad – *City:*
..........................................................................……

                        Država – *State:* .....................................................................................................................................................................

3.3.4. Davatelj licence ovlašten je za davanje licence na
temelju – *The licensor is authorized to
grant licence by virtue of:*

*..............................................................................................................................................................................................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

**IV.   PODACI O DOHOTKU
– *DESCRIPTION OF THE INCOME:***

        Ukupan iznos dohotka– *Total amount of income:*
..................................................................................................................................

        Datum isplate – *Date of payment:* ..........................................................................................................................................................

        Ukupan iznos poreza – *Total amount of tax:*  ........................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**V.    PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***...................................

        ...............................................................................................................................................................................................................

if !supportEmptyParas endif

**VI.   NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa – *To the account number: .............................................................................................................................................*

        Kod (banka) – *With the (Bank):
............................................................................................................................................................*

        Otvorenog na ime – *Opened in the name of:
........................................................................................................................................*

if !supportEmptyParas endif

**VII.  IZJAVA PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions:*

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak u smislu
navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren kroz djelatnost
registriranu u Republici Hrvatskoj – *He
did not derive income, as defined in the mentioned Agreement for the avoidance
of  double taxation, through the
activity registered in the Republic of Croatia,*

Poznato mi je da Porezna uprava
Republike Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja
zahtjeva davati podatke o sadržaju ovog zahtjeva – *I am aware of the fact that the Croatian Tax Administration can
disclose the information given in this Application to the tax authorities in the
country of residence of the claimant.*

if !supportEmptyParas endif

                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and date*                                                                                    Potpis - *Signature*

if !supportEmptyParas endif

**VIII. POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA ZAHTJEVA –
*CERTIFICATE OF TAX AUTHORITY OF
CLAIMANT´S COUNTRY OF RESIDENCE:***

        Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora o
izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i
.................................... – *The
claimant is the resident of ................................... under Article
.......... of the Agreement for the avoidance of double taxation between the
Republic of Croatia and ....................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

#

**if !supportEmptyParas endif**

PRIMJERAK
2

-
za isplatitelja dohotka -

COPY
2

-
for the payer of the income -

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX ADMINISTRATION***

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA

NA LICENCE I SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine – Međunarodni
ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR ROYALTIES UNDER

### THE AGREEMENT  FOR THE AVOIDANCE OF DOUBLE TAXATION BETWEEN

### THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 23. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 23 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

## I.              PODACI O StjecateljU licence – *INFORMATION ON THE LICENSEE:*

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik - *Legal form*:
.......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Zanimanje / djelatnost – *Occupation:*
.....................................................................................................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:* ....................................................................................................................................................

                Poštanski broj – *Postal code:*
...................................................Grad – *City:* ..................................................................................

                Država – *State:*
...............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - DavateljU licence – *INFORMATION ON THE CLAIMANT – LICENSOR:***

Ime i prezime / naziv tvrtke – *Full name / business name*: ....................................................................................................................

        Pravni oblik - *Legal form*:
.......................................................................................................................................................................

        Broj – *Number:*
.......................................................................................................................................................................................

        Zanimanje / djelatnost – *Occupation:*

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
.............................................Grad – *City:* ................................................................................……

                Država – *State:* ...............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

**III.    Predmet
ugovora o licenci – *SUBJECT MATTER OF
LICENCE:***

**if !supportEmptyParas endif**

**3.1. Prava
intelektualnog vlasništva – *Intellectual
property rights***

3.1.1. Vrste prava intelektualnog vlasništva – *Form of intellectual property right:*

........................................................................................................................................................................................................

                ........................................................................................................................................................................................................

3.1.2. Registracija prava intelektualnog vlasništva – *Registration of intellectual property right:*

                Država registracije – *Country of registration:*
.................................................................................................................................

                Broj registracije – *Registration number*:
.........................................................................................................................................

Datum registracije – *Date
of registration:*
.......................................................................................................................................

        3.1.3. Nositelj
prava intelektualnog vlasništva prema registru – *Registered owner  of
intellectual property right*:

                Ime i prezime / naziv tvrtke – *Full name / business name:*
............................................................................................................

                Pravni oblik - *Legal form*:
...............................................................................................................................................................

                Zanimanje / djelatnost – *Occupation:*
.............................................................................................................................................

                Prebivalište / sjedište – *Address:* ...................................................................................................................................................

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
................................................Grad – *City:*
............................................................................

                        Država – *State:* .....................................................................................................................................................................

**3.2. Prava na korištenje pokretnina** (između
ostalog leasing-ugovori) – *Right to
use  movable property (under a leasing
or an other agreement)*

3.2.1. Vrste pokretnina – *Type of movable
property:.............................................................................................................................*

                ........................................................................................................................................................................................................

**3.3 Autorska
prava** (prava koja ne
spadaju pod točku 3.1) – *Copyrights
(other than those under paragraph 3.1)*

3.3.1. Vrste autorskog prava – *Form of copyright*:
.................................................................................................................................

3.3.2. Naziv zaštićenog djela – *Title of protected work:
........................................................................................................................*

3.3.3. Autor - *Author*

        Ime – *Name:*
...................................................................................................................................................................................

Prezime – *Surname:*
.......................................................................................................................................................................

                Prebivalište / sjedište – *Address:*

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
...............................................Grad – *City:*
............................................................................

                        Država – *State:* .....................................................................................................................................................................

3.3.4. Davatelj licence ovlašten je za davanje licence na
temelju – *The licensor is authorized to
grant licence by virtue of:*

*..............................................................................................................................................................................................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

**IV.   PODACI O DOHOTKU
– *DESCRIPTION OF THE INCOME:***

        Ukupan iznos dohotka– *Total amount of income:*
..................................................................................................................................

        Datum isplate – *Date of payment:* ..........................................................................................................................................................

        Ukupan iznos poreza – *Total amount of tax:*  ........................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**V.    PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***.................................................................….

        ...............................................................................................................................................................................................................

if !supportEmptyParas endif

**VI.   NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa – *To the account number: ..........................................................................................................................…………….*

        Kod (banka) – *With the
(Bank):................................................................................................................................................*

        Otvorenog na ime – *Opened in the name of:
.........................................................................................................................................*

if !supportEmptyParas endif

**VII.  IZJAVA PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions*:

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak u smislu
navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren kroz
djelatnost registriranu u Republici Hrvatskoj – *He did not derive income, as defined in the mentioned Agreement for the
avoidance of  double taxation, through
the activity registered in the Republic of Croatia,*

Poznato mi je da Porezna uprava
Republike Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja
zahtjeva davati podatke o sadržaju ovog zahtjeva – *I am aware of the fact that the Croatian Tax Administration can
disclose the information given in this Application to the tax authorities in
the country of residence of the claimant.*

if !supportEmptyParas endif

                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and date*                                                                                    Potpis - *Signature*

if !supportEmptyParas endif

**VIII. POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA ZAHTJEVA –
*CERTIFICATE OF TAX AUTHORITY OF
CLAIMANT´S COUNTRY OF RESIDENCE:***

        Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora o
izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i
.................................... – *The
claimant is the resident of ................................... under Article
.......... of the Agreement for the avoidance of double taxation between the
Republic of Croatia and ....................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

PRIMJERAK
3

-
za Poreznu upravu Republike Hrvatske -

COPY
3

-
for the Tax Administration of the Republic of Croatia -

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX
ADMINISTRATION***

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA

NA LICENCE I SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine –
Međunarodni ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR ROYALTIES UNDER

### THE AGREEMENT  FOR THE AVOIDANCE OF DOUBLE TAXATION BETWEEN

### THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 23. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 23 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

## I.              PODACI O StjecateljU licence – *INFORMATION ON THE LICENSEE:*

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik - *Legal form*: .......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Zanimanje / djelatnost – *Occupation:*
.....................................................................................................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
..................................................Grad – *City:* ..................................................................................

                Država – *State:*
...............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - DavateljU licence – *INFORMATION ON THE CLAIMANT – LICENSOR:***

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik - *Legal form*:
.......................................................................................................................................................................

        Broj – *Number:* .......................................................................................................................................................................................

        Zanimanje / djelatnost – *Occupation:*

        Prebivalište / sjedište – *Address:* ...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
.................................................Grad – *City:*
..................................................................................

                Država – *State:*
...............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

**III.    Predmet
ugovora o licenci – *SUBJECT MATTER OF
LICENCE:***

**if !supportEmptyParas endif**

**3.1. Prava
intelektualnog vlasništva – *Intellectual
property rights***

3.1.1. Vrste prava intelektualnog vlasništva – *Form of intellectual property right:*

........................................................................................................................................................................................................

                ........................................................................................................................................................................................................

3.1.2. Registracija prava intelektualnog vlasništva – *Registration of intellectual property right:*

                Država registracije – *Country of registration:*
.................................................................................................................................

                Broj registracije – *Registration number*: .........................................................................................................................................

Datum registracije – *Date
of registration:*
.......................................................................................................................................

        3.1.3. Nositelj
prava intelektualnog vlasništva prema registru – *Registered owner  of
intellectual property right*:

                Ime i prezime / naziv tvrtke – *Full name / business name:* ............................................................................................................

                Pravni oblik - *Legal form*:
...............................................................................................................................................................

                Zanimanje / djelatnost – *Occupation:*
.............................................................................................................................................

                Prebivalište / sjedište – *Address:*
...................................................................................................................................................

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
................................................Grad – *City:*
............................................................................

                        Država – *State:*
.....................................................................................................................................................................

**3.2. Prava na korištenje pokretnina** (između
ostalog leasing-ugovori) – *Right to
use  movable property (under a leasing
or an other agreement)*

3.2.1. Vrste pokretnina – *Type of movable property:.............................................................................................................................*

                ........................................................................................................................................................................................................

**3.3 Autorska
prava** (prava koja ne
spadaju pod točku 3.1) – *Copyrights
(other than those under paragraph 3.1)*

3.3.1. Vrste autorskog prava – *Form of copyright*:
.................................................................................................................................

3.3.2. Naziv zaštićenog djela – *Title of protected work:
........................................................................................................................*

3.3.3. Autor - *Author*

        Ime – *Name:*
...................................................................................................................................................................................

Prezime – *Surname:*
.......................................................................................................................................................................

                Prebivalište / sjedište – *Address:*

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
...................................................Grad – *City:*
................................................................……..

                        Država – *State:* .....................................................................................................................................................................

3.3.4. Davatelj licence ovlašten je za davanje licence na
temelju – *The licensor is authorized to
grant licence by virtue of:*

*..............................................................................................................................................................................................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

**IV.   PODACI O DOHOTKU
– *DESCRIPTION OF THE INCOME:***

        Ukupan iznos dohotka– *Total amount of income:*
..................................................................................................................................

        Datum isplate – *Date of payment:* ..........................................................................................................................................................

        Ukupan iznos poreza – *Total amount of tax:*  ........................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**V.    PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***......................................................................

        ...............................................................................................................................................................................................................

if !supportEmptyParas endif

**VI.   NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa – *To the account number: ....................................................................................................................................…….*

        Kod (banka) – *With the (Bank):
...................................................……………………………………………………………………………..*

        Otvorenog na ime – *Opened in the name of:
.........................................................................................................................................*

if !supportEmptyParas endif

**VII.  IZJAVA PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions*:

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak u smislu
navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren kroz
djelatnost registriranu u Republici Hrvatskoj – *He did not derive income, as defined in the mentioned Agreement for the
avoidance of  double taxation, through
the activity registered in the Republic of Croatia,*

Poznato mi je da Porezna uprava
Republike Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja zahtjeva
davati podatke o sadržaju ovog zahtjeva – *I
am aware of the fact that the Croatian Tax Administration can disclose the
information given in this Application to the tax authorities in the country of
residence of the claimant.*

if !supportEmptyParas endif

                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and date*                                                                                    Potpis - *Signature*

if !supportEmptyParas endif

**VIII. POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA ZAHTJEVA –
*CERTIFICATE OF TAX AUTHORITY OF CLAIMANT´S
COUNTRY OF RESIDENCE:***

        Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora o
izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i
.................................... – *The
claimant is the resident of ................................... under Article
.......... of the Agreement for the avoidance of double taxation between the
Republic of Croatia and ....................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

# if !supportEmptyParas endif

# if !supportEmptyParas endif

**VIII. NAPOMENE POREZNE UPRAVE
REPUBLIKE HRVATSKE (ako ih ima) – CROATIAN TAX AUTHORITIES REMARKS (if any)**

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

# if !supportEmptyParas endif

PRIMJERAK
4

-
za inozemno porezno tijelo -

COPY
4

-
for the foreign tax authotity -

if !supportEmptyParas endif

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

***MINISTRY OF FINANCE – TAX
ADMINISTRATION***

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT
VIŠE PLAĆENOG POREZA

NA LICENCE I SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

**("Narodne novine –
Međunarodni ugovori", broj: ..…)**

### APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX REFUND FOR ROYALTIES UNDER

### THE AGREEMENT  FOR THE AVOIDANCE OF DOUBLE TAXATION BETWEEN

### THE REPUBLIC OF CROATIA AND .........................................

***("Official
Gazette – International Agreements", number: ..…)***

**if !supportEmptyParas endif**

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 23. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 23 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

## I.              PODACI O StjecateljU licence – *INFORMATION ON THE LICENSEE:*

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik - *Legal form*: .......................................................................................................................................................................

        Broj (JMBG ili matični broj) - *Number (identification number / tax number)*:
..........................................................................................

        Zanimanje / djelatnost – *Occupation:*
.....................................................................................................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

                Ulica i broj – *Street and number:* ....................................................................................................................................................

                Poštanski broj – *Postal code:*
.....................................................Grad – *City:* .......................................................................…….

                Država – *State:*
...............................................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**II.     PODACI O PODNOSITELJU ZAHTJEVA - DavateljU licence – *INFORMATION ON THE CLAIMANT – LICENSOR:***

Ime i prezime / naziv tvrtke – *Full name / business name*:
....................................................................................................................

        Pravni oblik - *Legal form*:
.......................................................................................................................................................................

        Broj – *Number:* .......................................................................................................................................................................................

        Zanimanje / djelatnost – *Occupation:*

        Prebivalište / sjedište – *Address:* ...........................................................................................................................................................

                Ulica i broj – *Street and number:*
....................................................................................................................................................

                Poštanski broj – *Postal code:*
.....................................................Grad – *City:*
...........................................................................….

                Država – *State:* ...............................................................................................................................................................................

**if !supportEmptyParas endif**

Ime i prezime / naziv zastupnika (ako ga ima) – *Name of the representative (if any):*
..........................................................................

        Prebivalište / sjedište – *Address:*
...........................................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

**III.    Predmet
ugovora o licenci – *SUBJECT MATTER OF
LICENCE:***

**if !supportEmptyParas endif**

**3.1. Prava
intelektualnog vlasništva – *Intellectual
property rights***

3.1.1. Vrste prava intelektualnog vlasništva – *Form of intellectual property right:*

........................................................................................................................................................................................................

                ........................................................................................................................................................................................................

3.1.2. Registracija prava intelektualnog vlasništva – *Registration of intellectual property right:*

                Država registracije – *Country of registration:*
.................................................................................................................................

                Broj registracije – *Registration number*:
.........................................................................................................................................

Datum registracije – *Date
of registration:*
.......................................................................................................................................

        3.1.3. Nositelj
prava intelektualnog vlasništva prema registru – *Registered owner  of
intellectual property right*:

                Ime i prezime / naziv tvrtke – *Full name / business name:* ............................................................................................................

                Pravni oblik - *Legal form*: ...............................................................................................................................................................

                Zanimanje / djelatnost – *Occupation:*
.............................................................................................................................................

                Prebivalište / sjedište – *Address:*
...................................................................................................................................................

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
...................................................Grad – *City:*
........................................................................

                        Država – *State:*
.....................................................................................................................................................................

**3.2. Prava na korištenje pokretnina** (između
ostalog leasing-ugovori) – *Right to
use  movable property (under a leasing
or another agreement)*

3.2.1. Vrste pokretnina – *Type of movable property:.............................................................................................................................*

                ........................................................................................................................................................................................................

**3.3 Autorska
prava** (prava koja ne
spadaju pod točku 3.1) – *Copyrights
(other than those under paragraph 3.1)*

3.3.1. Vrste autorskog prava – *Form of copyright*:
.................................................................................................................................

3.3.2. Naziv zaštićenog djela – *Title of protected work:
........................................................................................................................*

3.3.3. Autor - *Author*

        Ime – *Name:*
...................................................................................................................................................................................

Prezime – *Surname:*
.......................................................................................................................................................................

                Prebivalište / sjedište – *Address:*

                        Ulica i broj – *Street and number:*
...........................................................................................................................................

                        Poštanski broj – *Postal code:*
...................................................Grad – *City:*
.........................................................................

                        Država – *State:* .....................................................................................................................................................................

3.3.4. Davatelj licence ovlašten je za davanje licence na
temelju – *The licensor is authorized to
grant licence by virtue of:*

*..............................................................................................................................................................................................................*

if !supportEmptyParas endif

if !supportEmptyParas endif

**IV.   PODACI O DOHOTKU
– *DESCRIPTION OF THE INCOME:***

        Ukupan iznos dohotka– *Total amount of income:*
..................................................................................................................................

        Datum isplate – *Date of payment:* ..........................................................................................................................................................

        Ukupan iznos poreza – *Total amount of tax:*  ........................................................................................................................................

if !supportEmptyParas endif

if !supportEmptyParas endif

**V.    PRILOŽENI
DOKUMENTI (broj i naziv) – *Documents
attached (number and title):***......................................................................

        ...............................................................................................................................................................................................................

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**VI.   NAČIN POVRATA
VIŠE PLAĆENOG POREZA – *procedure of the refund:***

U Republici Hrvatskoj ili u – *In the Republic of Croatia or in:
.................................................................................................................*

        Na broj računa – *To the account number:
.............................................................................................................................................*

        Kod (banka) – *With the(Bank):
....................................................…………………………………………………………………………….*

        Otvorenog na ime – *Opened in the name of:
.........................................................................................................................................*

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**VII.  IZJAVA PODNOSITELJA ZAHTJEVA – *STATEMENT OF THE CLAIMANT:***

Potpisnik jamči da su gore navedeni
podaci istiniti te da podnositelj zahtjeva, naveden pod točkom II., ispunjava
slijedeće uvjete – *The undersigned
certifies that the beneficial owner
mentioned under II fulfills the following conditions*:

1.     Stvarni
je korisnik gore navedenog dohotka – *He
is the beneficial owner of the mentioned income*,

2.     Dohodak u smislu
navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren kroz
djelatnost registriranu u Republici Hrvatskoj – *He did not derive income, as defined in the mentioned Agreement for the
avoidance of  double taxation, through
the activity registered in the Republic of Croatia,*

Poznato mi je da Porezna uprava
Republike Hrvatske može poreznom tijelu u državi rezidentnosti podnositelja
zahtjeva davati podatke o sadržaju ovog zahtjeva – *I am aware of the fact that the Croatian Tax Administration can
disclose the information given in this Application to the tax authorities in
the country of residence of the claimant.*

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                ....................................................                                                                            ..........................................

Mjesto i datum – *Place and date*                                                                                    Potpis - *Signature*

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**VIII. POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA ZAHTJEVA –
*CERTIFICATE OF TAX AUTHORITY OF CLAIMANT´S
COUNTRY OF RESIDENCE:***

        Podnositelj zahtjeva je rezident
.................................. prema članku ............... Ugovora o
izbjegavanju dvostrukog oporezivanja između Republike Hrvatske i
.................................... – *The
claimant is the resident of ................................... under Article
.......... of the Agreement for the avoidance of double taxation between the
Republic of Croatia and ....................................*

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        ....................................................                    .....................................................                           ....................................................

        Mjesto i datum  - *Place and date*                                     Pečat - *Stamp*
                                                   Potpis - *Signature*

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*UPUTA ZA POPUNJAVANJE: **LICENCE***

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if !supportLists5.      endifOvaj
obrazac podnosi se radi umanjenja porezne obveze, izuzimanja od poreza ili
povrata više plaćenog poreza za licence i slična davanja osobi koja ima
prebivalište, uobičajeno boravište ili sjedište (rezidentu) u državi s kojom je
Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog oporezivanja.

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if !supportLists6.      endifObrazac
se sastoji od četiri primjerka. Prvi je primjerak za podnositelja zahtjeva,
drugi za isplatitelja, treći za Poreznu upravu Ministarstva financija Republike
Hrvatske, a četvrti za inozemno porezno tijelo. Točke II, IV, V i VI popunjava
podnositelj zahtjeva, točke I i III popunjava isplatitelj, a točku VII
popunjava inozemno porezno tijelo. Popunjeni i potpisani primjerci obrasca
predaju se inozemnim poreznim tijelima zemlje koje je primatelj rezident. Inozemna
porezna tijela će provesti potrebnu kontrolu, ovjeriti predočeni obrazac i
zadržati svoj primjerak, a podnositelju zahtjeva vratiti preostala tri
primjerka (za podnositelja zahtjeva, isplatitelja i Poreznu upravu Ministarstva
financija Republike Hrvatske).

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if !supportLists7.      endifZa
svakog isplatitelja i za svaku isplatu podnosi se poseban zahtjev.

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if !supportLists8.      endifZahtjev
za umanjenje porezne obveze, izuzimanje od poreza ili povrat više plaćenog
poreza podnosi se Ministarstvu financija Republike Hrvatske, Poreznoj upravi,
Područnom uredu Zagreb, Avenija Dubrovnik 32,
najkasnije u roku od tri godine od isteka kalendarske godine u kojoj je
isplata izvršena.

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*if !supportEmptyParas endif*

*if !supportEmptyParas endif*

*INSTRUCTIONS FOR FILLING IN THE FORM: **ROYALTIES***

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if !supportLists5.      endifThis
form is submitted for tax relief, tax exemption or tax refund for royalties to
a resident of the country with which the Republic of Croatia entered into
Agreement for the Avoidance of Double Taxation.

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if !supportLists6.      endifThe
form consists of four copies. The first copy is for the claimant, the second
for the payer of the income, the third copy for the Tax Administration of the
Republic of Croatia, and the forth copy for the foreign tax authority. Items
II, IV, V  and VI are to be filled in by
the claimant, items I and III  by the
payer of the income, and the item VII by the foreign tax authority. The filled
in and signed copies of the form are submitted to the tax authorities of the
country in which the recipient is resident. Foreign tax authorities shall carry
out the required control, certify a submitted form, and retain their own copy,
and return the three remaining copies to the claimant (for the claimant, payer
of the income, and the Tax Administration of the Republic of Croatia).

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if !supportLists7.      endifFor
each payer and for each payment a separate claim is made.

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if !supportLists8.      endifApplication
for tax relief, tax exemption or tax refund is submitted to the Ministry of
Finance of the Republic of Croatia, Tax Administration, Zagreb office, Avenija
Dubrovnik 32, at latest within 3 years as of expiry of the calendar year in
which the payment is effected.

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Ostalo, NN 1/2001-31
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