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	Pravilnik o porezu na dohodak
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                    <h2>Pravilnik o porezu na dohodak</h2>
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                                <h3>NN 1/2005 (3.1.2005.), Pravilnik o porezu na dohodak</h3>
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		mso-list-template-ids:8.237099E+08 -4.851644E+08 6.769871E+07 6.769871E+07 6.76987E+07 6.769871E+07 6.769871E+07 6.76987E+07 6.769871E+07 6.769871E+07;
}
@list l6:level1 {
		mso-level-start-at:4;
		mso-level-tab-stop:35.25pt;
		mso-level-number-position:left;
		margin-left:35.25pt;
		text-indent:-18pt;
}
@list l7 {
		mso-list-id:3.554237E+08;
		mso-list-type:hybrid;
		mso-list-template-ids:-1.183806E+09 1.239834E+09 6.881282E+07 6.881282E+07 6.881282E+07 6.881282E+07 6.881282E+07 6.881282E+07 6.881282E+07 6.881282E+07;
}
@list l7:level1 {
		mso-level-start-at:3;
		mso-level-number-format:roman-upper;
		mso-level-tab-stop:54pt;
		mso-level-number-position:left;
		margin-left:54pt;
		text-indent:-36pt;
}
@list l7:level2 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.';
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		margin-left:36pt;
		text-indent:-18pt;
}
@list l7:level3 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.%3.';
		mso-level-tab-stop:54pt;
		mso-level-number-position:left;
		margin-left:54pt;
		text-indent:-36pt;
}
@list l7:level4 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.%3.%4.';
		mso-level-tab-stop:54pt;
		mso-level-number-position:left;
		margin-left:54pt;
		text-indent:-36pt;
}
@list l7:level5 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.%3.%4.%5.';
		mso-level-tab-stop:54pt;
		mso-level-number-position:left;
		margin-left:54pt;
		text-indent:-36pt;
}
@list l7:level6 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.%3.%4.%5.%6.';
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		margin-left:72pt;
		text-indent:-54pt;
}
@list l7:level7 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.%3.%4.%5.%6.%7.';
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		margin-left:72pt;
		text-indent:-54pt;
}
@list l7:level8 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.%3.%4.%5.%6.%7.%8.';
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		margin-left:72pt;
		text-indent:-54pt;
}
@list l7:level9 {
		mso-level-legal-format:yes;
		mso-level-text:'%1.%2.%3.%4.%5.%6.%7.%8.%9.';
		mso-level-tab-stop:90pt;
		mso-level-number-position:left;
		margin-left:90pt;
		text-indent:-72pt;
}
@list l8 {
		mso-list-id:6.311807E+08;
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}
@list l8:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l8:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l8:level3 {
		mso-level-number-format:roman-lower;
		mso-level-tab-stop:108pt;
		mso-level-number-position:right;
		text-indent:-9pt;
}
@list l9 {
		mso-list-id:6.679064E+08;
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}
@list l9:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l9:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l10 {
		mso-list-id:7.91897E+08;
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}
@list l10:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l10:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l11 {
		mso-list-id:7.98767E+08;
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}
@list l11:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l11:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l11:level3 {
		mso-level-number-format:roman-lower;
		mso-level-tab-stop:108pt;
		mso-level-number-position:right;
		text-indent:-9pt;
}
@list l12 {
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}
@list l12:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l12:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l12:level3 {
		mso-level-number-format:roman-lower;
		mso-level-tab-stop:108pt;
		mso-level-number-position:right;
		text-indent:-9pt;
}
@list l13 {
		mso-list-id:9.051422E+08;
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}
@list l13:level1 {
		mso-level-tab-stop:35.25pt;
		mso-level-number-position:left;
		margin-left:35.25pt;
		text-indent:-18pt;
}
@list l14 {
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}
@list l14:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l14:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l15 {
		mso-list-id:1.01045E+09;
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}
@list l15:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l15:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l16 {
		mso-list-id:1.057242E+09;
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}
@list l16:level1 {
		mso-level-tab-stop:36pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l17 {
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}
@list l17:level1 {
		mso-level-tab-stop:36pt;
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		text-indent:-18pt;
}
@list l17:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
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		text-indent:-18pt;
}
@list l18 {
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}
@list l18:level1 {
		mso-level-tab-stop:36pt;
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		text-indent:-18pt;
}
@list l18:level2 {
		mso-level-number-format:alpha-lower;
		mso-level-tab-stop:72pt;
		mso-level-number-position:left;
		text-indent:-18pt;
}
@list l18:level3 {
		mso-level-number-format:roman-lower;
		mso-level-tab-stop:108pt;
		mso-level-number-position:right;
		text-indent:-9pt;
}
@list l19 {
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}
@list l19:level1 {
		mso-level-tab-stop:36pt;
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		text-indent:-18pt;
}
@list l20 {
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}
@list l20:level1 {
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		text-indent:-18pt;
}
@list l21 {
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}
@list l21:level1 {
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		text-indent:-18pt;
}
@list l21:level2 {
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		mso-level-tab-stop:72pt;
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}
@list l21:level3 {
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		text-indent:-9pt;
}
@list l22 {
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}
@list l22:level1 {
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}
@list l23:level1 {
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}
@list l23:level2 {
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}
@list l24:level1 {
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}
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}
@list l25:level1 {
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}
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}
@list l26:level2 {
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}
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}
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}
@list l26:level5 {
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		text-indent:-18pt;
}
@list l26:level6 {
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}
@list l26:level7 {
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}
@list l26:level8 {
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}
@list l26:level9 {
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}
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}
@list l27:level1 {
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}
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}
@list l28:level1 {
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}
@list l29:level1 {
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}
@list l29:level2 {
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}
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}
@list l29:level4 {
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}
@list l29:level5 {
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}
@list l29:level6 {
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}
@list l29:level7 {
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}
@list l29:level8 {
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}
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}
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}
@list l31:level1 {
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<div class="sl-content"><div class="doc"><div class="article-column leftcolumn fullwidth">

<div class=Section1>

<h1><span lang=EN-GB>MINISTARSTVO FINANCIJA</span></h1>

<p class=brojdesno2><span style='font-size:12.0pt;mso-bidi-font-size:11.0pt'>1<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Na
temelju članka 64. Zakona o porezu na dohodak (»Narod­ne novine« broj 177/04) i
članka 96. stavka 2. Zakona o doprinosima za obvezna osiguranja (»Narodne
novine« broj 147/02, 175/03 i 177/04) donosim<o:p></o:p></span></p>

<h2><span lang=EN-GB>PRAVILNIK</span><span style='mso-ansi-language:HR'><o:p></o:p></span></h2>

<h3><span lang=EN-GB>O</span><span lang=EN-GB style='mso-ansi-language:HR'> </span><span lang=EN-GB>POREZU</span><span lang=EN-GB style='mso-ansi-language:HR'> </span><span lang=EN-GB>NA</span><span lang=EN-GB style='mso-ansi-language:HR'> </span><span lang=EN-GB>DOHODAK</span><span style='mso-ansi-language:HR'><o:p></o:p></span></h3>

<p class=T-119sred><span style='font-size:12.0pt;mso-bidi-font-size:11.5pt'>1.
OPĆA ODREDBA<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
1.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Ovim se
Pravilnikom podrobnije razrađuje primjena pojedinih odredbi Zakona o porezu na
dohodak (u daljnjem tekstu: Zakon) i način izvješćivanja o doprinosima za
obvezna osiguranja prema Zakonu o doprinosima za obvezna osiguranja.<o:p></o:p></span></p>

<p class=T-119sred style='margin-bottom:0cm;margin-bottom:.0001pt'><span style='font-size:12.0pt;mso-bidi-font-size:11.5pt'>2. NEOPOREZIVE NAKNADE,
POTPORE, NAGRADE I DRUGI PRIMICI<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
2.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1) U
skladu s odredbama članka 14. stavka 1. točke 1. podtočke 1.2. Zakona primici
po osnovi naknada, potpora, nagrada, dnevnica i otpremnina smatraju se
primicima od nesamostalnog rada ako prelaze iznose iz stavka 2. ovoga članka.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(2) U
skladu s odredbama članka 10. točke 9. Zakona o opo­re­zivim primicima po
osnovi nesamostalnog rada ne smatraju se iznosi što ih poslodavci isplaćuju
svojim radnicima, i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>1.
naknade prijevoznih troškova na službenom putovanju u visini stvarnih izdataka,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>2.
naknade troškova noćenja na službenom putovanju u visini stvarnih izdataka,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>3.
naknade troškova prijevoza na posao i s posla mjesnim javnim prijevozom u
visini stvarnih izdataka, prema cijeni mjesečne odnosno pojedinačne prijevozne
karte,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>4.
naknade troškova prijevoza na posao i s posla među­mjesnim javnim prijevozom u
visini stvarnih izdataka, prema cijeni mjesečne odnosno pojedinačne karte. Ako
radnik mora sa stanice međumjesnoga javnog prijevoza koristiti i mjesni
prijevoz, stvarni izdaci utvrđuju se u visini troškova mjesnoga i među­mjesnoga
javnog prijevoza,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.
naknade za korištenje privatnog automobila u službene svrhe do 2,00 kune po
prijeđenom kilometru,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>6.
potpore zbog invalidnosti radnika do 2.500,00 kuna go­dišnje,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>7.
potpore za slučaj smrti radnika do 7.500,00 kuna,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>8.
potpore u slučaju smrti člana uže obitelji radnika (bračnog druga, roditelja,
roditelja bračnog druga, djece, drugih predaka i potomaka u izravnoj liniji,
usvojene djece i djece na skrbi te punoljetne osobe kojoj je porezni obveznik
imenovan skrbnikom prema posebnom zakonu) do 3.000,00 kuna,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>9.
potpore zbog neprekidnog bolovanja radnika dužeg od 90 dana do 2.500,00 kuna
godišnje. Razdoblje bolovanja duže od 90 dana ne mora se odnositi na jednu
kalendarsku godinu,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>10. dar
djetetu do 15 godina starosti do 400,00 kuna go­dišnje,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>11.
prigodne nagrade do 2.000,00 kuna godišnje (božićnica, naknada za godišnji
odmor, i sl.),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>12.
nagrade radnicima za navršenih:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>12.1. –
10 godina radnog staža do 1.500,00 kuna<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>12.2. –
15 godina radnog staža do 2.000,00 kuna<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>12.3. – 20 godina radnog staža do 2.500,00 kuna<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>12.4. – 25 godina radnog staža do 3.000,00 kuna<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>12.5. – 30 godina radnog staža do 3.500,00 kuna<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>12.6. – 35 godina radnog staža do 4.000,00 kuna<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>12.7. – 40 godina radnog staža do 5.000,00 kuna,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>13. dnevnice u zemlji do 170,00 kuna, za službeno
putovanje koje traje više od 12 sati dnevno. Za službena putovanja u zemlji
koja traju više od 8, a manje od 12 sati neoporezivi dio dnevnica iznosi do 85
kuna,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>14. dnevnice u inozemstvu do iznosa i pod uvjetima
utvrđenim propisima o izdacima za službena putovanja za korisnike državnog
proračuna,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>15. terenski dodatak u zemlji do 170,00 kuna dnevno
na ime pokrića troškova prehrane i drugih troškova radnika na terenu u zemlji,
osim troškova smještaja koji se podmiruju na teret poslodavca i ne smatraju se
dohotkom radnika,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>16. terenski dodatak u inozemstvu do 250,00 kuna
dnevno na ime pokrića troškova prehrane i drugih troškova zaposlenika na terenu
u inozemstvu, osim troškova smještaja koji se podmiruju na teret poslodavca i
ne smatraju se dohotkom radnika,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>17.
pomorski dodatak do 250,00 kuna dnevno,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>17.a
pomorski dodatak na brodovima međunarodne plovidbe do 400,00 kuna dnevno,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>18.
naknade za odvojeni život od obitelji do 1.600,00 kuna mjesečno,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>19.
otpremnine prilikom odlaska u mirovinu do 8.000,00 kuna,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>20.
otpremnine radi poslovno uvjetovanih otkaza i osobno uvjetovanih otkaza, prema
Zakonu o radu, do visine 6.400,00 kuna za svaku navršenu godinu rada kod tog
poslodavca i otpremnine radi ozljede na radu ili profesionalne bolesti do
visine 8.000,00 kuna za svaku navršenu godinu rada kod tog poslodav­ca.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(3)
Dnevnice za službena putovanja u zemlji i inozemstvu isplaćuju se za putovanja
iz mjesta u kojemu je mjesto rada radnika koji se upućuje na službeno putovanje
u drugo mjesto (osim u mjesto u kojemu ima prebivalište ili uobičajeno
boravište), a udaljenosti najmanje 30 kilometara, radi obavljanja u nalogu za
službeno putovanje određenih poslova njegova radnog mjesta, a u svezi s
djelatnosti poslodavca. Dnevnice za službena putovanja u zemlji i inozemstvu
jesu naknade za pokriće izdataka prehrane, pića i prijevoza u mjestu u koje je
radnik upućen na službeno putovanje.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(4)
Terenski dodatak u tuzemstvu i inozemstvu isplaćuje se kada radnik boravi izvan
mjesta svojega prebivališta ili uobi­čajenog boravišta radi poslova koje
obavlja izvan sjedišta poslodavca ili sjedišta izdvojene poslovne jedinice
poslodavca i kada poslodavac obavlja takvu vrstu djelatnosti koja je po svojoj
prirodi vezana za rad na terenu (mjesto rada se razlikuje od mjesta sjedišta
poslodavca ili njegove poslovne jedinice i mjesta prebivališta ili uobičajenog
boravišta radnika, pri čemu je mjesto rada udaljeno od tih mjesta najmanje 30
kilometara). Terenski dodatak može se pod ovim uvjetima isplatiti i u slučaju
kada ne postoji potreba za noćenjem radnika na terenu.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(5) Terenski dodatak u inozemstvu iz stavka 2. točke
16. ovoga članka odnosi se na radnike upućene odnosno raspoređene na rad u
inozemstvo po osnovi radnog odnosa zasnovanog s poslodavcem u Republici
Hrvatskoj.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(6) Pomorski dodatak iz stavka 2. točke 17. ovoga
članka primjenjuje se za pomorce na brodovima pod hrvatskom zastavom (duga
plovidba, velika obalna plovidba – Mediteran i mala obalna plovidba – Jadran).<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(7) Pomorski dodatak iz stavka 2. točke 17.a ovoga
članka primjenjuje se i za pomorce na brodovima pod stranom zastavom na temelju
potvrde stranog isplatitelja o isplaćenim primanjima koju porezni obveznici
prilažu uz svoju godišnju poreznu prijavu.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(8) Naknada za odvojeni život od obitelji isplaćuje
se radniku za vrijeme provedeno na radu u mjestu sjedišta poslodavca ili
njegove izdvojene poslovne jedinice, ako je mjesto rada različito od mjesta
prebivališta ili uobičajenog boravišta tog radnika.<u><o:p></o:p></u></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(9) U skladu s člankom 10. točkom 9. Zakona,
oporezivim primicima po osnovi nesamostalnog rada ne smatraju se naknade iz
stavka 2. točaka 1., 2., 3., 4., 5., 13. i 14. ovoga članka koje tuzemni isplatitelj
isplaćuje fizičkim osobama iz članka 14. stavka 1. točke 3. Zakona izaslanima
na rad u Republiku Hrvatsku po nalogu inozemnog poslodavca, a za službena
putovanja u vezi s djelatnosti tuzemnog isplatitelja.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(10) U skladu s člankom 10. točkom 9. Zakona,
oporezivim primicima po osnovi nesamostalnog rada ne smatraju se naknade iz
stavka 2. točaka 1., 2., 3., 4., 5., 13. i 14. ovoga članka koje se isplaćuju
članovima predstavničkih i izvršnih tijela državne vlasti te jedinica lokalne i
područne (regionalne) samouprave iz članka 14. stavka 1. točke 4. Zakona, a za
potrebe obavljanja poslova iz toga djelokruga.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(11) U
skladu s člankom 10. točkom 9. Zakona, oporezivim primicima po osnovi
nesamostalnog rada ne smatraju se naknade iz stavka 2. ovoga članka koje se
isplaćuju prema članku 14. stav­ku 1. točki 5. Zakona osobama koje pružaju
njegu i pomoć hrvatskim ratnim vojnim invalidima iz Domovinskog rata I.
skupine, a za potrebe obavljanja tih poslova.<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
3.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1)
Oporezivim primicima ne smatraju se naknade iz članka 2. stavka 2. točaka 1.,
2., 3., 4., 5., 13. i 14. ovoga Pravilnika isplaćene prema članku 10. točki 11.
Zakona fizičkim osobama koje nisu radnici i osobe koje ostvaruju primitke po
osnovi nesamostalnog rada iz članka 14. Zakona ili ne ostvaruju primitke iz
članka 32. Zakona, uz naknadu u neprofitnim organizacijama.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(2)
Oporezivim primicima ne smatraju se naknade iz članka 2. stavka 2. točaka 1.,
2., 3., 4., 5., 13., 14., 15., 16., 17., 17.a i 18. ovoga Pravilnika što ih
isplatitelji isplaćuju osobama koje se nakon završenog školovanja nalaze na
obveznom praktičnom radu ili na dobrovoljnoj praksi.<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
4.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>U
skladu s odredbama članka 10. točke 10. Zakona, poreznim obveznicima koji
obavljaju samostalne djelatnosti iz članka 18. Zakona, kao poslovni izdaci
priznaju se iznosi naknada, potpora i nagrada za njih osobno, u visini i na
način propisan člankom 2. ovoga Pravilnika.<o:p></o:p></span></p>

<p class=Clanak style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>Članak 5.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(1) Isplate iz članka 2. ovoga Pravilnika priznaju se
na temelju vjerodostojnih isprava (računa, obračuna, odluka, potvrda o cijeni
karata i drugog).<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) Naknade iz članka 2. stavka 2. točaka 13., 14.,
15., 16., 17., 17.a i 18. ovoga Pravilnika međusobno se isključuju. Naknada za
odvojeni život umanjuje se za iznos isplaćenih dnevnica, terenskih ili pomorskih
dodataka tijekom mjeseca za koji se naknada isplaćuje.<o:p></o:p></span></p>

<p class=Clanak style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>Članak 6.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(1) Oporezivim primicima fizičkih osoba koje
ostvaruju drugi dohodak iz članka 32. Zakona ne smatraju se iznosi što ih
isplaćuju isplatitelji i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>1.
nagrade učenicima za vrijeme praktičnog rada i naukovanja iz članka 10. točke
4. Zakona do visine 1.600,00 kuna mjesečno,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>2.
primici po posebnim propisima učenika i studenata na redovnom školovanju za rad
preko učeničkih i studentskih udruga iz članka 10. točke 6. Zakona do visine
50.000,00 kuna godišnje,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>3. stipendije iz članka 10. točke 12. Zakona
učenicima i studentima za redovno školovanje na srednjim, višim i visokim
školama te fakultetima do visine 1.600,00 kuna mjesečno,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>4. športske stipendije koje uključuju i naknade prema
članku 10. točki 14. i 16. Zakona koje se prema posebnim propisima isplaćuju
športašima za njihovo športsko usavršavanje do 1.600,00 kuna mjesečno,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>5. nagrade za športska ostvarenja iz članka 10. točke
16. Zakona prema posebnim propisima do 20.000,00 kuna godišnje.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) Stipendijom iz stavka 1. točke 3. ovoga članka
smatra se stipendija učenicima i studentima za redovno školovanje na sred­njim,
višim i visokim školama te fakultetima, uz uvjet da ju učenik ili student u
poreznom razdoblju prima samo kod jednog isplatitelja ili kod više isplatitelja
do ukupno 1.600,00 kuna mjesečno.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(3)
Športskim stipendijama iz stavka 1. točke 4. ovoga članka smatraju se:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>a)
olimpijske stipendije koje primaju športaši koji su ispunili odgovarajuću normu
za nastup na Olimpijskim igrama, a koju propisuje pripadajuća međunarodna
športska asocijacija određenog športa za određenu disciplinu koja je uvrštena u
program Olimpijskih igara,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>b)
stipendije kategoriziranih športaša prema Pravilniku o kategorizaciji športaša
kojeg u skladu s odredbama Zakona o športu donosi Hrvatski olimpijski odbor, a
koje isplaćuju Hrvat­ski olimpijski odbor, županijske i gradske športske
zajednice te športski klubovi<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(4)
Stipendije iz stavka 1. točke 3. i 4. ovoga članka među­sobno se ne isključuju.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(5)
Nagradama za športska ostvarenja iz stavka 1. točke 5. ovoga članka smatraju se
nagrade određene prema Pravilniku o kategorizaciji športaša i Pravilniku o
mjerilima za dodjelu nagrada koji donosi nadležno ministarstvo na prijedlog
Hrvatskog olimpijskog odbora, a koje isplaćuju Hrvatski olimpijski odbor,
športski savezi na razini gradova i županija odnosno nacionalni športski savezi
te športske zajednice u gradovima i županijama i športski klubovi.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(6)
Porezni obveznik koji ostvaruje primitke za rad preko učeničkih i studentskih
udruga iz stavka 1. točke 2. ovoga članka obvezan je isplatitelju primitka do
trenutka isplate dostaviti vjerodostojne isprave o ostvarenim primicima po
osnovi rada preko učeničkih i studentskih udruga u tijeku poreznog razdoblja
odnosno izjavu ako nije ostvario primitke po toj osnovi. <o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(7)
Isplatitelji su obvezni primitke iz stavka 1. točke 1. do 5. ovoga članka
isplaćivati obveznicima poreza na dohodak na njihov žiroračun otvoren kod
ovlaštene organizacije za platni promet.<o:p></o:p></span></p>

<p class=T-119sred><span style='font-size:12.0pt;mso-bidi-font-size:11.5pt'>3.
PRIMICI PO OSNOVI NESAMOSTALNOG RADA U NARAVI<o:p></o:p></span></p>

<p class=T-109curz><span style='font-size:12.0pt;mso-bidi-font-size:10.5pt'>3.1.
Opće odredbe<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
7.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1)
Primicima po osnovi nesamostalnog rada u skladu s člankom 14. stavkom 3. Zakona
smatraju se i primici radnika i drugih osoba koje ostvaruju primitke odnosno
plaću iz članka 14. Zakona u stvarima i uslugama koje imaju novčanu vrijednost
(dobra, usluge, prava i ostala primanja u naravi), u koje posebice ulaze:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>1. korištenje poslovnih zgrada i njihovih dijelova,
garaža, odmarališta i kuća za odmor, stambenih zgrada i stanova, prije­voznih
sredstava koje poslodavac i isplatitelj primitka odnosno plaće omogućuje
radniku i osobama koje ostvaruju primitke iz članka 14. Zakona,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>2. korištenje kredita uz kamate ispod stope od 4%
godišnje,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>3. primici ostvareni u uslugama bez naknade, raznim
darovima i ugošćenjima. Ugošćenjima se smatraju primici koje poslodavac i
isplatitelj primitka odnosno plaće omogućuje radniku i drugim osobama koje
ostvaruju primitke iz članka 14. Zakona u vidu konzumacije jela, pića,
smještaja, rekreacije i slično. Ugošće­njima u smislu ovoga Pravilnika ne
smatraju se ugošćenja predstavnika poslovnih partnera ako se na dokumentaciji o
tim izdacima navede naziv poduzetnika čiji su predstavnici ugošćeni,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>4.
primici po osnovi naknada i nagrada za rad u dionicama,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5. svi
drugi primici po osnovi i u svezi s nesamostalnim radom koji se daju u naravi,
osim izravnih ili neizravnih novčanih isplata i doznaka.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(2)
Povoljnijim kreditima iz stavka 1. točke 2. ovoga članka ne smatraju se krediti
koji se radnicima i osobama koje ostvaruju primitke iz članka 14. Zakona, osim
radnicima u upravi, daju ili subvencioniraju iz proračuna, bez obzira pod kojim
uvjetima su odobreni.<o:p></o:p></span></p>

<p class=T-109curz><span style='font-size:12.0pt;mso-bidi-font-size:10.5pt'>3.2.
Utvrđivanje vrijednosti primitaka u naravi<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
8.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1) Vrijednost
primitaka iz članka 7. ovoga Pravilnika utvrđuje se prema tržišnoj vrijednosti
tih primitaka koja je važeća u mjestu davanja (s uključenim porezom na dodanu
vrijednost).<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(2) Ako
su primici u naravi odobreni radniku uz plaćanje naknade koja je niža od
tržišne, poslodavac i isplatitelj primitka mora utvrditi razliku između tržišne
cijene i naknade koju je radnik platio. Tako utvrđena razlika smatra se
primitkom po osnovi nesamostalnog rada.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(3) Ako
isplatitelj ne utvrdi oporezive primitke iz članka 7. ovoga Pravilnika ili ti
primici nisu utvrđeni prema tržišnoj cijeni, njihovu visinu i poreznu osnovicu
utvrđuje ispostava Porezne uprave nadležna prema sjedištu ili prebivalištu
isplatitelja.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(4)
Vrijednost primitaka iz članka 7. ovoga Pravilnika utvrđuje se na sljedeći
način:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>l. pri
korištenju poslovnih zgrada i njihovih dijelova – primitak čini iznos zakupnine
ili najamnine prema tržišnim cijenama u mjestu u kojem se poslovne zgrade ili
dijelovi poslovnih zgrada nalaze,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>2. pri korištenju stambenih zgrada i stanova –
primitak je iznos stanarine prema tržišnim cijenama u mjestu u kojem se
stambene zgrade ili dijelovi stambenih zgrada nalaze,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>3. pri korištenju odmarališta i kuća za odmor –
primitak je tržišna vrijednost smještaja, prehrane i drugih usluga,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>4. pri korištenju garaža – primitak je iznos
zakupnine prema tržišnim cijenama u mjestu u kojem se garaža nalazi,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5. pri
korištenju prijevoznih sredstava – primitak je iznos u visini od l% nabavne
vrijednosti prijevoznih sredstava mjesečno, bez obzira na opseg korištenja
prijevoznih sredstava u privatne svrhe ili se primitak utvrđuje prema opsegu
stvarnog korištenja.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.1.
Ako se prijevozna sredstva daju na korištenje u privatne svrhe, poslodavac i
isplatitelj primitka odnosno plaće obvezan je donijeti odluku o načinu i
uvjetima tog korištenja, kao i načinu utvrđivanja plaće radnika i osoba koje
ostvaruju primitke iz članka 14. Zakona po toj osnovi.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.2.
Ako se plaća po osnovi korištenja prijevoznog sredstva u privatne svrhe
utvrđuje prema opsegu stvarnog korištenja, poslodavac i isplatitelj primitka
odnosno plaće obvezan je voditi evidenciju o prijeđenoj kilometraži i/ili
vremenu korištenja u privatne svrhe, a način vođenja te evidencije utvrđuje
odlukom iz točke 5.l. ovoga stavka.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.3.
Ako se ne vodi evidencija iz točke 5.2. ovoga stavka, primitak u naravi od
korištenja prijevoznih sredstava u privatne svrhe utvrđuje se u visini 1%
nabavne vrijednosti prijevoznih sred­stava mjesečno.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.4.
Ako više radnika ili osoba koje ostvaruju primitke iz članka 14. Zakona tijekom
mjeseca koriste isto prijevozno sredstvo, a poslodavac i isplatitelj primitka
odnosno plaće osnovicu utvrđuje u visini 1% nabavne vrijednosti prijevoznih
sredstava mjesečno, odgovarajući iznos primitka po toj osnovi pribraja svakom
radniku i osobi.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.5.
Primitak po osnovi korištenja prijevoznih sredstava u privatne svrhe utvrđuje
se prema stvarnom opsegu korištenja na sljedeći način:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.5.1.
za cestovna motorna vozila – na iznos koji se dobije tako da se ukupno
prijeđena kilometraža u privatne svrhe pomnoži s 2,00 kune po prijeđenom
kilometru.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.5.2.
za plovila – na iznos dobiven umnoškom broja sati korištenja i tržišne cijene
sata korištenja plovila u mjestu u kojem je plovilo registrirano.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5.5.3.
za sredstva zračnog prometa – na iznos koji se dobije umnoškom broja sati
korištenja i tržišne cijene sata korištenja u mjestu registracije.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>6. pri
korištenju kredita uz kamate ispod stope 4% godišnje – na razliku između kamata
obračunanih primjenom stope kamate od 4% godišnje (uključujući i porez na dodanu
vrijednost) i ugovorenih nižih kamata.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>7. pri
davanju darova, usluga bez naknade i slično čija je pojedinačna vrijednost
preko 400,00 kuna po pojedinom radniku i osobama koje ostvaruju primitke iz
članka 14. Zakona godišnje – na vrijednost iste ili slične vrste stvari odnosno
usluge prema tržnim cijenama u mjestu davanja dara ili usluge. Pod darovima se
u smislu ovoga Pravilnika, smatraju samo davanja u naravi,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>8. pri
ugošćenjima – na vrijednost ugošćenja prema tržišnim cijenama u mjestu
ugošćenja,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>9. pri
davanju dionica – na tržišnu vrijednost dionica.<o:p></o:p></span></p>

<p class=T-119sred><span style='font-size:12.0pt;mso-bidi-font-size:11.5pt'>4.
OBVEZE POSLODAVCA I ISPLATITELJA PRIMITKA ODNOSNO PLAĆE I MIROVINE<o:p></o:p></span></p>

<p class=T-109curz><span style='font-size:12.0pt;mso-bidi-font-size:10.5pt'>4.1.
Obveze glede izvješćivanja<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
9.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1)
Poslodavci i isplatitelji primitka odnosno plaće i mirovine ili sam porezni
obveznik, sukladno odredbi članka 46. stavka 5. Zakona, o isplaćenom dohotku od
nesamostalnog rada i obračunanom te uplaćenom porezu na dohodak prema članku
45., stavcima 1., 7. i 8. Zakona, sastavljaju i Poreznoj upravi dostav­ljaju
mjesečno izvješće.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) Obveznici obračunavanja i plaćanja doprinosa za
obvezna osiguranja, sukladno odredbi članka 78. stavka 1. točka 2. Zakona o
doprinosima za obvezna osiguranja, o obračunanim doprinosima za obvezna
osiguranja prema člancima 66. i 67. toga Zakona, sastavljaju i Poreznoj upravi
dostavljaju mjesečno izvješće.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(3) Izvješće prema stavku 2. ovoga članka sastavljaju
i dostavljaju obveznici iz članka 4. Zakona o doprinosima za obvezna osiguranja
i to: <o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>1. iz točaka 2.2, 5.2, 30. i 30.a – poslodavac za radnika
u radnom odnosu, općenito, te isplatitelj primitaka (plaće) članu
predstavničkog tijela ili izvršnog tijela državne vlasti i jedinice lokalne i
područne (regionalne) samouprave<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>2. iz točke 3. – poslodavac stalnog sezonskog radnika<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>3. iz točke 4. – poslodavac koji je primio volontera,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>4. iz točaka 12., 13. i 14.4. – osiguranik po osnovi
obavljanja samostalne djelatnosti obrta, slobodnog zanimanja ili poljoprivrede
i šumarstva koji od te djelatnosti plaća porez na dobit i osiguranik po osnovi
trgovac pojedinac upisan u registar trgovačkog suda te<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5. iz
točke 45.2 – isplatitelj naknade osobi koja pruža pomoć i njegu hrvatskom
ratnom vojnom invalidu.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(4)
Izvješće iz stavaka 1. i 2. ovoga članka podnosi se za svaki izvještajni
mjesec, s ukupnim podacima za sve radnike i druge primatelje te ostale osobe
koje su ostvarile primitke iz članka 14. Zakona odnosno za sve osobe osigurane
po osnovi rada za poslodavca za čije su osiguranje obračunani doprinosi za
obvezna osiguranja, ispostavi Porezne uprave prema sjedištu podnositelja
(pravne osobe) odnosno prema prebivalištu/uobi­čajenom boravištu (fizičke osobe
i ostali podnositelji izvješća) do 15. dana u mjesecu za protekli mjesec na
Obrascu ID – »Izvješće o primicima od nesamostalnog rada (plaći i mirovini),
porezu na dohodak i prirezu te doprinosima za obvezna osiguranja u mjesecu
_____ godine ____« koji je sastavni dio ovoga Pravilnika.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(5)
Obrazac ID sadržava sljedeće podatke:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;1.
Pod I. podatke o podnositelju izvješća:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;2.
pod 1. naziv odnosno ime i prezime<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;3.
pod 2. adresu: sjedišta pravne osobe (i podnositelja koji nisu pravne niti
fizičke osobe) a prebivališta odnosno uobiča­jenog boravišta fizičke osobe<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;4.
pod 3. matični broj (podnositelja pravne osobe) ili matični broj građana
(podnositelja fizičke osobe) odnosno sistemski broj koji podnositelju izvješća
dodjeljuje Porezna uprava kada je riječ o podnositelju koji nema matični broj
niti jedinstveni matični broj<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;5. pod 4. identifikator obrasca.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;6. Pod II. podatke o iznosima isplaćenih
primitaka iz članka 14. Zakona, izdacima prema članku 16. Zakona te dohotku,
iznosu osobnih odbitaka, iznosu porezne osnovice te iznosima obračunanog i
uplaćenog poreza na dohodak i prireza i to:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;7. pod 1. o iznosu ukupno isplaćenih primitaka<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;8. pod 2. o iznosu ukupnih izdataka a koji se
sastoje od:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;9. pod 2.1. iznosa uplaćenih doprinosa iz plaće
za obvezna osiguranja te:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>10. pod 2.1.1. iznosa uplaćenog doprinosa za
mirovinsko osiguranje na temelju generacijske solidarnosti<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>11. pod 2.1.2. iznosa uplaćenog doprinosa za mirovinsko
osiguranje na temelju individualne kapitalizirane štednje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>12. pod 2.1.3. iznosa uplaćenih doprinosa za
mirovinsko osiguranje, zdravstveno osiguranje i zapošljavanje u ukupnom iznosu,
koji su obračunani iz plaće koja se odnosi na razdoblje do 31. prosinca 2002.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>13. pod 2.2. iznosa uplaćenih premija osiguranja koje
je poslodavac obustavio od plaće i uplatio u ime i u korist radnika i to:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>14. pod 2.2.1. iznosa premije životnog osiguranja s
obilježjem štednje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>15. pod 2.2.2. iznosa premije dopunskoga i privatnoga
zdrav­stvenog osiguranja<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>16. pod
2.2.3. iznosa premije dobrovoljnog mirovinskog osiguranja<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>17. pod
3. o iznosu dohotka prema članku 13. Zakona<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>18. pod
4. o iznosu osobnih odbitaka prema članku 36. stav­cima 1. i 2. Zakona<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>19. pod
5. o iznosu porezne osnovice prema članku 45. stav­ku 4. Zakona<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>20. pod
6. o iznosu ukupno obračunanog poreza na dohodak i prireza i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>21. pod
6.1. o iznosu obračunanog poreza na dohodak<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>22. pod
6.2. o iznosu obračunanog prireza porezu na dohodak<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>23. pod
7. o iznosu ukupno uplaćenog poreza na dohodak i prireza<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24. pod
8. o broju radnika i ostalih primatelja, odnosno umirovljenika kojima je
isplaćena mirovina<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>25. Pod
III. podatke o vrsti doprinosa za obvezna osiguranja i iznosima obračunanih
doprinosa:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>26. pod
1. za mirovinsko osiguranje na temelju generacijske solidarnosti:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>27. pod
1.1. o iznosu obračunanog doprinosa za mirovinsko osiguranje na temelju
generacijske solidarnosti<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>28. pod
1.2. o iznosu obračunanog dodatnog doprinosa za mirovinsko osiguranje na
temelju generacijske solidarnosti za staž osiguranja koji se računa s povećanim
trajanjem<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>29. pod
2. za mirovinsko osiguranje na temelju individualne kapitalizirane štednje:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>30. pod
2.1. o iznosu obračunanog doprinosa za mirovinsko osiguranje na temelju individualne
kapitalizirane štednje<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>31. pod
2.2. o iznosu obračunanog dodatnog doprinosa za mirovinsko osiguranje na
temelju individualne kapitalizirane štednje za staž osiguranja koji se računa s
povećanim trajanjem<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>32. pod
3. za zdravstveno osiguranje:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>33. pod
3.1. o iznosu obračunanog doprinosa za osnovno zdravstveno osiguranje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>34. pod 3.2. o iznosu obračunanog posebnog doprinosa
za zdravstveno osiguranje za prava u slučaju ozljede na radu i profesionalne
bolesti<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>35. pod 3.3. o iznosu obračunanog posebnog doprinosa
za korištenje zdravstvene zaštite u inozemstvu<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>36. pod 4. za osiguranje u slučaju nezaposlenosti:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>37. pod 4.1. o iznosu obračunanog doprinosa za
zapošlja­vanje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>38. pod 4.2. o iznosu obračunanog posebnog doprinosa
za zapošljavanje osoba s invaliditetom<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>39. pod 5. o broju zaposlenih odnosno osiguranih
osoba po osnovi rada ili samostalne djelatnosti od koje se plaća porez na dobit<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>40. Pod IV. Podatke o ukupno obračunanom porezu na
dohodak i prirezu porezu na dohodak, prema općinama i gradovima u kojima
posloprimci imaju prebivalište ili uobičajeno boravište, i to<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>41. u stupcu 1. redni broj<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>42. u stupcu 2. šifra općine/grada<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>43. u stupcu 3. naziv općine/grada<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>44. u stupcu 4. o iznosu obračunanog poreza na
dohodak u zbirnom iznosu za sve radnike s prebivalištem/uobičajenim boravištem
na području pojedinoga grada/općine<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>45. u
stupcu 5. o iznosu obračunanog prireza porezu na do­hodak u zbirnom iznosu za
sve radnike s prebivalištem/uobiča­jenim boravištem na području pojedinoga
grada/općine i<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>46. u
stupcu 6. o ukupnom iznosu obračunanog poreza na dohodak i prireza porezu na
dohodak u zbirnom iznosu za sve radnike s prebivalištem/uobičajenim boravištem
na području pojedinoga grada/općine.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(6) Za izvještajni mjesec u kojemu nije bilo isplate
primitaka iz članka 14. Zakona ne popunjavaju se podaci pod II.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(7) Kada se u izvještajnom mjesecu obračunava i
isplaćuje plaća koja se odnosi na razdoblje do 31. prosinca 2002. (zaostala
plaća), doprinosi se prema toj plaći obračunavaju prema propisima koji su
vrijedili na dan 31. prosinca 2002., u skladu s odredbom članka 87. stavka 2.
Zakona o doprinosima za obvezna osiguranja, a o tome se izvješćuje na sljedeći
način:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>1. doprinosi koji su uplaćeni najkasnije s isplatom zaostale
plaće iskazuju se kao izdatak u ukupnom iznosu svih doprinosa iz plaće (za
mirovinsko osiguranje, zdravstveno osiguranje i za zapošljavanje), na Obrascu
ID pod II. 2.1.3.,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>2. svi doprinosi obračunani iz osnovice i na osnovicu
iskazuju se na Obrascu ID pod III., u odgovarajuće retke, ovisno o kojem se
doprinosu radi, zajedno s doprinosima obračunanim prema redovitoj plaći
dospjeloj za isplatu u izvještajnom mjesecu.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(8) Poslodavac koji je prema zaostaloj plaći iz
stavka 7. ovoga članka obračunao doprinose prema najnižoj mjesečnoj osnovici i
tako obračunane doprinose iskazao na Obrascu ID kao predujam doprinosa za
izvještajni mjesec kada su tako obračunani doprinosi dospjeli na naplatu, u
izvještajnom mjesecu u kojemu isplaćuje zaostalu plaću i obračunava doprinose
prema toj plaći, na Obrascu ID pod III. iskazuje iznose obračunanih doprinosa,
u odgovarajuće retke, ovisno o kojem se doprinosu radi, umanjene za iznose
istih doprinosa obračunanih prema najnižoj mjesečnoj osnovici i iskazanih kao
predujam doprinosa na Obrascu ID za izvještajni mjesec u kojem je predujam
doprinosa dospio na naplatu. <o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(9) Iznimno od odredbe stavka 4. ovoga članka,
podnositelj izvješća dostavlja više obrazaca ID za isto obračunsko razdoblje, u
posebnim slučajevima, pri čemu obrasce označava identifikatorom na Obrascu ID
pod I.4. i to:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>1. brojkom <b>1</b> kada izvješćuje o podacima koji
se odnose na primitke odnosno doprinose za:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>– radnike u radnom odnosu, općenito,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>– doprinose za produženo mirovinsko osiguranje
sezonskog radnika,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>– doprinose za osiguranje volontera,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>– primitak po osnovi rada u diplomatskoj misiji ili
konzularnom uredu strane države te međunarodnoj organizaciji ili predstavništvu
sa sjedištem u Republici Hrvatskoj, koji uživaju diplomatski imunitet (članak
45. stavak 7. Zakona),<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>– primitak (plaću) neposredno iz inozemstva (članak
45. stavak 8. Zakona);<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>2. brojkom <b>2</b> kada izvješćuje o podacima koji
se odnose na primitke (plaću) i doprinose članova predstavničkih i izvršnih
tijela državne vlasti i jedinica lokalne i područne (regionalne) samouprave<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>3. brojkom <b>3</b> kada izvješćuje o podacima koji
se odnose na poduzetničku plaću i doprinose prema poduzetničkoj plaći<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>4. brojkom <b>4</b> kada izvješćuje o podacima koji
se odnose mirovinu<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>5. brojkom <b>5</b> kada izvješćuje o podacima koji
se odnose na naknadu plaće i doprinose za osobe koje pružaju pomoć i njegu
ratnim vojnim invalidima<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>6. brojkom <b>6</b> kada izvješćuje o podacima koji
se odnose na primitke i doprinose za izaslane radnike<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>7. brojkom <b>7</b> kada izvješćuje o podacima koji
se odnose na pri­mitke i doprinose za radnika zaposlenog za poslove u kućanstvu
poslodavca.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(10) Izaslanim radnikom smatra se radnik koji za
poslodavca sa sjedištem u Republici Hrvatskoj obavlja posao u drugoj državi te
osoba koja radi u diplomatskoj misiji ili konzularnom uredu Republike Hrvatske
u inozemstvu, u skladu s odredbama Zakona o doprinosima za obvezna osiguranja
te osoba izaslana na rad u Republiku Hrvatsku po nalogu inozemnog poslodavca u
tuzemna društva za rad u tim društvima, kada ostvaruje primitke prema članku
14. stavku 1. točka 3. Zakona.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(11) Porezni obveznik koji po osnovi obavljanja
samostalne djelatnosti plaća porez na dobit a osiguran je po istoj osnovi i
obveznik je doprinosa za osobna osiguranja prema članku 4. točke 12., 13. i
14.4. Zakona o doprinosima za obvezna osiguranja, podatke o isplaćenoj
poduzetničkoj plaći (osnovici za obračun doprinosa iz članka 14. stavka 1. toga
Zakona) i doprinosima prema toj osnovici iskazuje na Obrascu ID i u slučaju
kada se poduzetnička plaća ne isplaćuje (osnovici za obračun doprinosa iz
članka 14. stavka 2. istoga Zakona). Obrazac ID sastavlja i dostavlja i za
mjesec u kojemu nije bilo isplate poduzetničke plaće za prethodni mjesec. U
slučaju supoduzetništva, Obrazac ID sastavlja se za svakog poduzetnika posebno.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(12) Obrazac ID može se dostaviti ispisan putem
računala, uz uvjet da sadržajem i oblikom u cijelosti odgovara obrascu koji je
propisan ovim Pravilnikom.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(13) Obrazac ID potpisuje ovlaštena osoba
podnositelja izvješća, koja pečatom i potpisom jamči za istinitost i točnost
iskazanih podataka.<span style='mso-tab-count:2'>                  </span><o:p></o:p></span></p>

<p class=T-109curz><span style='font-size:12.0pt;mso-bidi-font-size:10.5pt'>4.2.
Način popunjavanja izvješća o plaći i mirovini – obrasca IP<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
10.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1)
Poslodavac, isplatitelj primitka odnosno plaće i mirovine i sam porezni
obveznik po osnovi utvrđivanja predujma poreza na dohodak od nesamostalnog rada
prema članku 45. stavku 7. i 8. Zakona, popunjava »Izvješće o plaći i mirovini«
– Obrazac IP iz članka 11. ovoga Pravilnika, koji je sastavni dio ovoga
Pravilnika, na temelju podataka iz »Evidencije o dohotku od nesamostalnog rada«
ili analitičke evidencije plaća te drugih isprava (isplatnih lista, knjige
blagajne, izvatka žiroračuna, naloga za uplatu odnosno isplatu i slično).
Podaci se unose u obrazac najkasnije u roku 15 dana od proteka mjeseca u kojemu
su isplaćene primici po osnovi plaća ili mirovina.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) U Obrazac IP unose se podaci za cijelu godinu ili
dio godine u kojem je bilo isplata. Ako dohodak nije redovito mjesečno
isplaćivan, u odgovarajuće se retke obrazaca za pojedini mjesec upisuju oznake
»0,00«. Unesene podatke u obrazac IP poslodavac, isplatitelj primitka odnosno
plaće i mirovine ovjerava pečatom i potpisom.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(3) U Obrazac IP ne unose se podaci o uplaćenim
obveznim doprinosima iz plaće od propisane osnovice prema posebnom zakonu ako u
pojedinom mjesecu poreznog razdoblja plaća ili mirovina nisu isplaćene. Ti
podaci iskazuju se u mjesecu isplate toga dohotka.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.3pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(4) U obrazac iz stavka 1. ovoga članka podaci se
unose putem računala, strojno, odnosno ručno tintom ili kemijskom olov­kom.
Uneseni podaci ne smiju se brisati ni ispravljati; ako se pogriješi, pogrešku
treba precrtati vodoravnom crtom, uz pečat i potpis odgovorne osobe.<o:p></o:p></span></p>

<p class=T-109curz><span style='font-size:12.0pt;mso-bidi-font-size:10.5pt'>4.3.
Sadržaj i popunjavanje izvješća o plaći i mirovini – obrasca IP<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
11.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1)
Izvješće o plaći i mirovini – Obrazac IP sadrži podatke o:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>1. poslodavcu,
isplatitelju primitka odnosno plaće i mirovine iz članka 14. Zakona (pod I.),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>2.
radniku, umirovljeniku i osobama koje ostvaruju primitke iz članka 14. Zakona
(pod II.)<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>3.
isplaćenim plaćama i mirovinama, uplaćenim doprinosima za obvezna osiguranja iz
plaće, uplaćenom porezu, prirezu i premijama životnog osiguranja s obilježjem
štednje, dopunskog i privatnoga zdravstvenog i dobrovoljnoga mirovinskog
osiguranja (pod III.) uz posebnu oznaku – identifikator i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>1.
identifikator 1 za poslodavce, isplatitelje primitka odnosno plaće i mirovine
kojima su radnici, umirovljenici i osobe koje ostvaruju primitke iz članka 14.
Zakona dostavili poreznu karticu – obrazac PK po osnovi kojih ostvaruju pravo
na osobni odbitak pri utvrđivanju predujma poreza na dohodak od nesamostalnog
rada prema članku 46. stavcima 1. i 2. Zakona,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>2. identifikator 2 za poslodavce, isplatitelje
primitka odnosno plaće i mirovine kojima radnici, umirovljenici i osobe koje
ostvaruju primitke iz članka 14. Zakona nisu dostavili poreznu karticu –
obrazac PK i pri utvrđivanju predujma poreza na dohodak od nesamostalnog rada
ne mogu koristiti osobni odbitak iz članka 36. stavaka 1. i 2. Zakona.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) Pod točkom I. Obrasca IP unose se opći podaci o
poslodavcu, isplatitelju primitka odnosno plaće i mirovine: naziv/ime i
prezime, matični broj odnosno matični broj građana i adresa
sjedišta/prebivališta ili uobičajenog boravišta (mjesto, ulica i kućni broj).<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(3) Pod točkom II. Obrasca IP unose se podaci o
radniku, umirovljeniku i osobi koja ostvaruje primitke iz članka 14. Zakona:
ime i prezime, adresa prebivališta ili uobičajenog boravišta, matični broj
građana ili sistemski broj dodijeljen od Porezne uprave,<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(4) Pod točkom III. Obrasca IP unose se sljedeći
podaci:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;1. mjesec u kojemu je isplaćena plaća i
mirovina, bez obzira za koje je razdoblje isplaćena (stupac 1) te mjesečni
podaci o:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;2. šifra općine/grada prebivališta ili
uobičajenog boravišta (stupac 2)<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;3. iznosu isplaćene plaće i mirovine (stupac
3),<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;4. uplaćenim doprinosima za obvezna osiguranja
iz plaće (stupac 4),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;5.
uplaćenim porezno priznatim premijama osiguranja (stupac 5),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;6.
iznosu dohotka (stupac 6),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;7.
iznosu ukupnog osobnog odbitka prema članku 36. stavku 1. i/ili 2. Zakona, a
najviše do visine dohotka (stupac 7),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;8.
poreznoj osnovici (stupac 8),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;9.
iznosu uplaćenog poreza na dohodak i prireza porezu na dohodak (stupac 9),<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>10.
iznosu neto isplate (stupac 10).<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(5) Ako
mjesečni primitak od nesamostalnog rada pojedinog radnika, umirovljenika i
osobe koja ostvaruje primitak od nesamostalnog rada iz članka 14. Zakona nakon
odbitka doprinosa za obvezna osiguranja iz plaće nije dovoljan za pokriće
iznosa uplaćenih premija osiguranja i/ili ukupnog odnosno dijela mjesečnog
osobnog odbitka, u odgovarajuće stupce 5 i/ili 7 pod točkom III., upisuje se
odgovarajući iznos premija osiguranja i/ili osobnog odbitka koji se iz dohotka
može pokriti, a u stupac 9 upisuje se oznaka »0,00«.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(6)
Podaci o plaćama i mirovinama istodobno ostvareni kod drugih poslodavaca i
isplatitelja primitaka odnosno plaće i mirovine iz članka 14. Zakona ili kod
poslodavaca i isplatitelja primitaka odnosno plaće i mirovine iz članka 14.
Zakona kojima radnici, umirovljenici i druge osobe koje ostvaruju primitke od
nesamostalnog rada nisu predali obrazac PK, iskazuju se na Obrascu IP, bez
popunjavanja stupca 5 i 7.<o:p></o:p></span></p>

<p class=T-119sred><span style='font-size:12.0pt;mso-bidi-font-size:11.5pt'>5.
PREDUJAM POREZA PO ODBITKU<o:p></o:p></span></p>

<p class=T-109curz><span style='font-size:12.0pt;mso-bidi-font-size:10.5pt'>5.1.
Obveze isplatitelja dohotka iz kojeg se predujam plaća po odbitku<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
12.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1)
Isplatitelji primitaka i sam porezni obveznik, sukladno odredbi članka 48.
stavka 4. Zakona, o isplaćenim primicima od kojih se utvrđuje drugi dohodak te
obračunanom i uplaćenom predujmu poreza na dohodak prema članku 48. stavcima 2.
i 3. Zakona, sastavljaju i Poreznoj upravi dostavljaju mjesečno izvješće.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(2)
Obveznici obračunavanja i plaćanja doprinosa za obvezna osiguranja, sukladno
odredbi članka 78. stavka 1. točke 2. Zakona o doprinosima za obvezna
osiguranja, o obračunanim doprinosima za obvezna osiguranja prema članku 68.
Zakona o doprinosima za obvezna osiguranja, sastavljaju i Poreznoj upravi
dostavljaju mjesečno izvješće.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><i><span style='font-size:
12.0pt;mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span></span></i><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(3) Izvješće prema stavku 2.
ovoga članka sastavljaju i dostavljaju obveznici iz članka 4. Zakona o
doprinosima za obvezna osiguranja i to:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>1. iz točke 6. – osoba koja primitak od kojega se utvrđuje
drugi dohodak naplati neposredno iz inozemstva ili od druge fizičke osobe koja
ne obavlja samostalnu djelatnost<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>2. iz točke 7. – isplatitelj primitka od kojega se
utvrđuje drugi dohodak<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>3. iz točke 8. – isplatitelj primitka za rad učenika
i redovitih studenata (posrednik pri zapošljavanju učenika i redovitih
studenata)<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span>(4) Izvješće
iz stavaka 1. i 2. ovoga članka podnosi se za izvještajni mjesec u kojemu su
izvršene isplate primitaka od kojih se utvrđuje drugi dohodak prema članku 32.
Zakona, s ukupnim podacima za sve primatelje, ispostavi Porezne uprave prema
sjedištu podnositelja (pravne osobe) odnosno prema prebivalištu/uobičajenom
boravištu (fizičke osobe i ostali podnositelji izvješća) do 15. dana u mjesecu
za protekli mjesec na Obrascu IDD – »Izvješće o drugom dohotku, obračunanom i
uplaćenom porezu na dohodak i prirezu te doprinosima za obvezna osiguranja u
mjesecu _____ godine ____« koji je sastavni dio ovoga Pravilnika.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span>(5) Obrazac IDD sadržava sljedeće podatke:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>1. pod
I. podatke o podnositelju izvješća:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>2. pod
1. naziv odnosno ime i prezime<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>3. pod
2. adresu sjedišta odnosno prebivališta ili uobičajenog boravišta i to
grad/mjesto, ulicu i kućni broj<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>4. pod
3. matični broj (podnositelj pravna osoba) ili matični broj građana
(podnositelj fizička osoba) odnosno sistemski broj koji podnositelju izvješća
dodjeljuje Porezna uprava kada se radi o osobi koja nema matični broj niti
jedinstveni matični broj.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>5. Pod
II. opis podataka koji se iskazuju na obrascu te vrste primitaka od kojih se
utvrđuje drugi dohodak, prema članku 32. Zakona, i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>6. pod
A), u stupcu 2., opis vrste doprinosa i ostalih podataka koji se iskazuju
vodoravno u pojedinim stupcima od 3. do 9.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>7. pod
1. o broju primatelja koji su ostvarili primitke<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>8. pod
2. o primicima iz članka 32. stavci 3. i 5. Zakona<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>9. pod
3. o izdacima u visini 30% ostvarenih primitaka prema članku 32. stavak 5.
Zakona koji se upisuju u stupcima 5., 6. i 7. a u stupcu 5. upisuje se dodatno
i iznos izdatka od 25% ostvarenog primitka kada je riječ o umjetničkom
autorskom honoraru za umjetničko djelo, prema članku 22. Zakona o pravima
samostalnih umjetnika i poticanju kulturnog i umjetničkog stvaralaštva
(»Narodne novine«, broj 43/96)<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>10. pod
4. o osnovici za obračun doprinosa, razlici između primitaka iskazanih u retku
2. te izdataka iskazanih u retku 3.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>11. pod
5 o obračunanim doprinosima i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>12. pod
5.1. za mirovinsko osiguranje na temelju generacijske solidarnosti<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>13. pod 5.2. za mirovinsko osiguranje na temelju
generacijske solidarnosti za osobe osigurane u određenim okolnostima<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>14. pod 5.3. za mirovinsko osiguranje na temelju
individualne kapitalizirane štednje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>15. pod 5.4. za osnovno zdravstveno osiguranje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>16. pod 5.5. poseban doprinos za zdravstveno
osiguranje za osobe osigurane u određenim okolnostima<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>17. pod 5.6. poseban doprinos za zdravstveno
osiguranje za korištenje zdravstvene zaštite u inozemstvu<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>18. pod 6. o izdacima za doprinose, prema članku 32.
stavku 4. Zakona<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>19. pod 7. o osnovici za obračun poreza na dohodak,
odnosno iznosu primitka iskazanog pod 2. umanjenog za iznos izdatka iskazanih
pod 3. te umanjenog za iznos izdataka za doprinose iskazanog pod 6.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>20. pod 8. o obračunanom predujmu poreza na dohodak<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>21. pod 9. o obračunanom prirezu porezu na dohodak te<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>22. pod 10. o uplaćenom porezu na dohodak i prirezu.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23. Pod B) podaci o vrsti primitaka od kojih se
utvrđuje drugi dohodak, u stupcima 3. do 8. te ukupno u stupcu 9. sve prema
vrstama primitaka prema članku 32. stavcima 3. i 5. Zakona i to:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>24. u stupcu 3. podaci o primicima iz članka 32. stavka
3. Zakona u koji se unose podaci vezani uz primitke:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.1.
po osnovi djelatnosti članova skupština i nadzornih odbora trgovačkih društava,
upravnih odbora, upravnih vijeća i drugih njima odgovarajućih tijela drugih
pravnih osoba, članova povjerenstava i odbora koje imaju ta tijela i sudaca
porotnika koji nemaju svojstvo djelatnika u sudu (članak 32. stavak 3. točka 1.
Zakona) <o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.2.
po osnovi djelatnosti športaša koji nisu osigurani po osnovi bavljenja sportom
(članak 32. stavak 3. točka 3. Zakona)<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.3.
po osnovi djelatnosti trgovačkih putnika, agenata, akvizitera, športskih sudaca
i delegata, tumača, prevoditelja, turis­tičkih djelatnika, konzultanata,
sudskih vještaka te druge slične djelatnosti (članak 32. stavak 3. točka 4.
Zakona)<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.4.
primici u naravi – korištenje zgrada, prometnih sredstava, povoljnije kamate
pri odobravanju kredita i druge pogodnosti prema članku 14. stavku 3. ovoga
Zakona, a koje davatelji tih primitaka daju fizičkim osobama koje nisu njihovi
radnici i osobe koje ostvaruju primitke iz članka 14. Zakona (članak 32. stavak
3. točka 5. Zakona)<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.5.
nagrade za športska ostvarenja i naknade športašima prema posebnim propisima, i
to iznosi isplaćeni iznad propisanog (neoporezivog) iznosa (članak 32. stavak
3. točka 10. Zakona);<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.6.
ostali posebno nenavedeni primici koje fizičkim osobama isplaćuju ili daju
pravne i fizičke osobe (obveznici poreza na dobit i obveznici poreza na dohodak
koji obavljaju samostalne djelatnosti) i drugi isplatitelji i davatelji (članak
32. stavak 3. točka 11. Zakona), kao što su:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.6.1.
primitak člana predstavničkog tijela ili izvršnog tijela državne vlasti,
jedinica područne (regionalne) samouprave i jedinica lokalne samouprave koji po
osnovi članstva u tim tijelima nije obvezno osiguran te<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>24.6.2.
ostali slični primici oporezivi porezom na dohodak ili iznosi primitaka
isplaćeni iznad propisanog (neoporezivog) iznosa;<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>25. u
stupcu 4. podaci o primicima iz članka 32. stavka 3. Zakona i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>25.1.
nagrade učenicima za vrijeme praktičnog rada i naukovanja i to iznosi isplaćeni
iznad propisanog (neoporezivog) iznosa (članak 32. stavak 3. točka 6. Zakona)<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>25.2.
stipendije učenicima i studentima za redovno školovanje na srednjim, višim i
visokim školama i fakultetima i to iznosi isplaćeni iznad propisanog (neoporezivog)
iznosa (članak 32. stavak 3. točka 8. Zakona)<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>25.3. športske stipendije koje se prema posebnim
propisima isplaćuju športašima za njihovo športsko usavršavanje i to iznosi
isplaćeni iznad propisanog (neoporezivog) iznosa (članak 32. stavak 3. točka 9.
Zakona)<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>26. u stupcu 5. podaci o primicima iz članka 32.
stavka 5. točke 1. Zakona (autorskih naknada isplaćenih prema posebnom zakonu
kojim se uređuju autorska i srodna prava uključujući i naknade za isporučeno
umjetničko djelo osobama koje obavljaju umjetničku i kulturnu djelatnost)<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>27. u stupcu 6. podaci o primicima iz članka 32.
stavka 5. točke 2. Zakona (profesionalnih djelatnosti novinara, umjetnika i
športaša koji su osigurani po toj osnovi i doprinose za obvezna osiguranja
plaćaju prema rješenju)<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>28. u stupcu 7. podaci o primicima iz članka 32.
stavka 5. točke 3. Zakona (primitaka nerezidenata za obavljanje umjet­ničke,
artističke, zabavne, športske, književne i likovne djelatnosti te djelatnosti u
svezi s tiskom, radijem i televizijom te zabavnim priredbama) i to
nerezidentima čiji primici podliježu obvezi doprinosa i nerezidentima čiji
primici ne podliježu obvezi doprinosa<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>29. u stupcu 8. podaci o primicima iz članka 32.
stavka 3. točke 7. Zakona (primici učenika i studenata na redovnom školovanju
za rad preko učeničkih i studentskih udruga), polazeći od primitka – iznosa
koji se isplaćuje učeniku odnosno studentu (pod rednim brojem 2.), a iznos
osnovice za obračun poreza na dohodak (pod rednim brojem 7.) jest iznos koji se
dobije nakon što se primitak (iskazan pod rednim brojem 2.) umanji za
neoporezivi iznos te za izdatak za doprinose koji se odnosi na drugi dohodak,
odnosno dio primitka iznad neoporezivog iznosa <o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>30. u
stupcu 9. zbrojeni podaci pojedinačno iskazani vodo­rav­no, u stupcima 3. do 8.
prema vrsti podatka iz stupca 2. Obrasca IDD.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(5)
Podaci vezani uz primitak nerezidenta a koji se ne odnose na primitak iz članka
32. stavka 5. točke 3. Zakona, upisuju se u odgovarajući stupac ovisno o vrsti
primitka.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(6)
Obrazac IDD može se dostaviti ispisan putem računala, uz uvjet da sadržajem i
oblikom u cijelosti odgovara obrascu koji je propisan ovim Pravilnikom.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(7)
Obrazac IDD potpisuje ovlaštena osoba podnositelja izvješća, koja pečatom i
potpisom jamči za istinitost i točnost iskazanih podataka.<o:p></o:p></span></p>

<p class=T-109curz><span style='font-size:12.0pt;mso-bidi-font-size:10.5pt'>5.2.
Posebne obveze izvješćivanja o obračunanim i uplaćenim doprinosima za obvezna
osiguranja<o:p></o:p></span></p>

<p class=Clanak style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>Članak 13.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(1) Obveznici obračunavanja i plaćanja doprinosa za
obvezna osiguranja, sukladno odredbi članka 78. stavka 1. točka 2. Zakona o
doprinosima za obvezna osiguranja, o obračunanim doprinosima za obvezna
osiguranja prema člancima 67. i 69. Zakona o doprinosima za obvezna osiguranja,
sastavljaju i Poreznoj upravi dostavljaju mjesečno izvješće.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) Izvješće prema stavku 2. ovoga članka sastavljaju
i dostavljaju obveznici iz članka 4. Zakona o doprinosima za obvezna osiguranja
i to:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;1. iz točke 18. – tijelo državne uprave te
drugi subjekt<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;2. iz točke 19. – Hrvatski zavod za
zapošljavanje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;3. iz točke 20. – Hrvatski zavod za zdravstveno
osiguranje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;4. iz točke 21. – Centar za socijalnu skrb<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;5. iz točke 22. – Hrvatski zavod za mirovinsko
osiguranje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;6. iz točke 30. – osiguranik po osnovi
obavljanja samostalne djelatnosti obrta, slobodnog zanimanja ili poljoprivrede
i šumarstva u slučaju kada putuje na službeni put u inozemstvo<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;7. iz točke 35. – pravna i fizička osoba, za
osobu koja je prekinula rad zbog upućivanja na obrazovanje, stručno
usavršavanje ili poslijediplomski studij<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;8. iz točke 36. – pravna i fizička osoba za
osobu koju je prije stupanja u radni odnos, kao svojeg stipendistu uputila na
praktični rad kod druge osobe radi stručnog osposobljavanja ili usavršavanja<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>&nbsp;9. iz točke 37. – pravna i fizička osoba ili
nadležno tijelo državne uprave koje upućuje osobu u inozemstvo u sklopu
međunarodne tehničko-prosvjetne i kulturne suradnje<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>10. iz točke 38. – pravna i fizička osoba ili
nadležno tijelo državne vlasti kada ugovorom o stipendiranju stranaca preuzme
obvezu plaćanja zdravstvenog osiguranja stranaca<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>11. iz točke 39. – škola i visoko učilište ili drugo
nadležno tijelo za osiguranje učenika i studenata na praktičnom radu i<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.7pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>12. iz točke 40. – škola i visoko učilište za
osiguranje učenika i studenata koji nisu osigurani kao članovi obitelji
osiguranika.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span>(3) Izvješće iz stavka 1. ovoga članka podnosi
se za izvještajni mjesec u kojemu je izvršena isplata naknada plaće koja je
propisana osnovicom za obračun doprinosa, člankom 23. Zakona o doprinosima za
obvezna osiguranja odnosno za izvještajni mjesec u kojemu je dospjela obveza
obračuna i plaćanja doprinosa prema propisnoj osnovici, s ukupnim podacima za
sve primatelje odnosno za sve osiguranike za čije su osiguranje obračunani
doprinosi za obvezna osiguranja prema naknadi plaće ili prema propisnoj
mjesečnoj osnovici, ispostavi Porezne uprave prema sjedištu podnositelja
(pravne osobe) odnosno prema prebivalištu/uobičajenom boravištu (fizičke osobe
i ostali podnositelji izvješća) do 15. dana u mjesecu za protekli mjesec na
Obrascu IDD-1 – »Izvješće o isplaćenoj naknadi plaće te o osnovicama i obračunanim
i uplaćenim doprinosima za obvezna osiguranja u mjesecu _____ godine ____« koji
je sastavni dio ovoga Pravilnika.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span>(4) Obrazac IDD-1 sadržava sljedeće podatke:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;1.
Pod I. podatke o podnositelju izvješća:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;2.
pod 1. naziv odnosno ime i prezime<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;3.
pod 2. adresu sjedišta odnosno prebivališta ili uobičajenog boravišta<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;4.
pod 3. matični broj (podnositelj pravna osoba) ili matični broj građana
(podnositelj fizička osoba) odnosno sistemski broj koji podnositelju izvješća
dodjeljuje Porezna uprava u slučaju kada se radi o osobi koja nema matični broj
niti jedinstveni matični broj.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;5.
Pod II. podatke o obvezniku plaćanja doprinosa:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;6.
pod 1. naziv odnosno ime i prezime<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;7.
pod 2. adresu sjedišta<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;8.
pod 3. matični broj.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>&nbsp;9.
Pod III opis podataka koji se iskazuju na obrascu pod A) te vrste i iznosi
osnovice za obračun doprinosa, iznosi obračunanih doprinosa, pod B) i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>10. pod
A), u stupcu 2. opis i vrste doprinosa za obvezna osiguranja i ostalih podataka
koji se iskazuju vodoravno u pojedinim stupcima od 3. do 8.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>11. pod
1. o broju primatelja odnosno osiguranika<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>12. pod
2. o iznosu isplaćene naknade plaće odnosno osnovice<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>13. pod
3. o obračunanim doprinosima i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>14. pod
3.1. za mirovinsko osiguranje na temelju generacijske solidarnosti<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>15. pod
3.2. za mirovinsko osiguranje na temelju generacijske solidarnosti za staž
osiguranja koji se računa s povećanim trajanjem<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>16. pod
3.3. za mirovinsko osiguranje na temelju generacijske solidarnosti u za osobe
osigurane određenim okolnostima<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>17. pod
3.4. za mirovinsko osiguranje na temelju individualne kapitalizirane štednje<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>18. pod
3.5. za mirovinsko osiguranje na temelju individualne kapitalizirane štednje za
staž osiguranja koji se računa s povećanim trajanjem<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>19. pod
3.6. za osnovno zdravstveno osiguranje<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>20. pod
3.7. poseban doprinos za zdravstveno osiguranje za slučaj ozljede na radu i
profesionalne bolesti<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>21. pod
3.8. poseban doprinos za zdravstveno osiguranje za osobe osigurane u određenim
okolnostima<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>22. pod
3.9. poseban doprinos za zdravstveno osiguranje za korištenje zdravstvene
zaštite u inozemstvu<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>23. pod
B) podaci o vrsti osnovice za obračun doprinosa prema Zakonu o doprinosima za
obvezna osiguranja, iznosima osnovice te iznosima doprinosa iskazani u stupcima
od 3. do 8. i to:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>23.1. u
stupcu 3. podaci o osnovici propisanoj člankom 21. Zakona o doprinosima za
obvezna osiguranja, za osiguranje korisnika invalidske mirovine zbog
profesionalne nesposobnosti za rad iz članka 25. stavak 6. Zakona o mirovinskom
osiguranju za koje doprinose obračunava Hrvatski zavod za mirovinsko
osiguranje, a plaća ih Republika Hrvatska putem nadležnog ministarstva (članak
4. točka 17.2. Zakona o doprinosima za obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>23.2. u
stupcu 4. podaci o osnovici propisanoj člankom 22. Zakona o doprinosima za obvezna
osiguranja za osiguranika invalidnu osobu iz članka 7. Zakona o stažu
osiguranja koji se računa s povećanim trajanjem za koje doprinose obračunava
Hrvatski zavod za mirovinsko osiguranje a plaća ih Republika Hrvatska putem
nadležnog ministarstva (članak 4. točka 17.5. Zakona o doprinosima za obvezna
osiguranja);<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.3. u stupcu 4. podaci o osnovici propisanoj
člankom 23. Zakona o doprinosima za obvezna osiguranja za osiguranika –
korisnika naknade plaće, čiji je obveznik obračunavanja i plaćanja Hrvatski
zavod za zdravstveno osiguranje (članak 4. točka 20.1. Zakona o doprinosima za
obvezna osiguranja), Hrvat­ski zavod za mirovinsko osiguranje (članak 4. točka
22.1.) i centar za socijalnu skrb (članak 4. točka 21. Zakona o doprinosima za
obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.4. u stupcu 6. podaci o osnovici propisanoj
člankom 23.a Zakona o doprinosima za obvezna osiguranja za osiguranika –
samostalnog umjetnika iz članka 5. Zakona o pravima samostalnih umjetnika i
poticanju kulturnog i umjetničkog stvaralaštva za koje doprinose za mirovinsko
osiguranje obračunava Hrvatski zavod za mirovinsko osiguranje a doprinose za
zdravstveno osiguranje Hrvatski zavod za zdravstveno osiguranje, a plaća ih
Republika Hrvatska putem nadležnog ministarstva (članak 4. točka 17.6. Zakona o
doprinosima za obvezna osiguranja;<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.5. u stupcu 7. podaci o osnovici propisanoj
člankom 24. Zakona o doprinosima za obvezna osiguranja, odnosno najnižoj
mjesečnoj osnovici i doprinosima obračunanim prema najnižoj mjesečnoj osnovici
i to:<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.5.1. za osiguranje roditelja iz članka 15. Zakona
o mirovinskom osiguranju prema kojoj doprinose obračunava Hrvatski zavod za
mirovinsko osiguranje a plaća ih Republika Hrvatska putem nadležnog
ministarstva (članak 4. točka 17.1. Zakona o doprinosima za obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.4pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.5.2. za osiguranje u određenim okolnostima učenika
i studenata na praktičnom radu iz članka 18. stavka 1. točke 1. i stav­ka 2.
Zakona o mirovinskom osiguranju i članka 13. točke 1. Zakona o zdravstvenom
osiguranju prema kojoj doprinose obračunava škola ili visoko učilište a plaća
ih Republika Hrvatska putem nadležnog ministarstva (članak 4. točka 17.3.
Zakona o doprinosima za obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>23.5.3.
za osiguranika u određenim okolnostima iz članka 18. stavak 1. točka 3. i
članaka 19. i 20. Zakona o mirovinskom osiguranju i članka 12. točke 1. do 3. i
članka 13. točke 2. i točke 4. do 10. Zakona o zdravstvenom osiguranju za koje
doprinose obračunavaju i plaćaju tijela državne uprave (članak 4. točka 18.
Zakona o doprinosima za obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>23.5.4.
za osiguranika nezaposlenu osobu iz članka 10. stavak 2. Zakona o mirovinskom
osiguranju i nezaposlenu osobu iz članka 18. stavak 1. točka 2. Zakona o
mirovinskom osiguranju za koje doprinose obračunava i plaća Hrvatski zavod za
zapošljavanje (članak 4. točka 19. Zakona o doprinosima za obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.9pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.5.5. za osiguranika po osnovi obavljanja
samostalne djelatnosti koji doprinose plaća prema rješenju Porezne uprave, a u
slučaju kada osobno putuje na službeni put u inozemstvo, za koje doprinose
obračunava i plaća sam osiguranik po osnovi obavljanja samostalne djelatnosti
(članak 4. točka 30. Zakona o doprinosima za obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.9pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.5.6. za osiguranje svake osobe koju pravna ili
fizička osoba ili tijelo državne uprave osigurava a osnova osiguranja nije
radni odnos niti isplata drugog dohotka i kada doprinose obračunava i plaća ta
pravna ili fizička osoba ili tijelo državne uprave (članak 4. točke 35., 36.,
37., 38., i 39. Zakona o doprinosima za obvezna osiguranja);<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.9pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>23.5.7. za osiguranje učenika i studenata koji nisu
osigurani kao članovi obitelji prema kojoj doprinose obračunava i plaća škola
odnosno visoko učilište (članak 4. točka 40. Zakona o doprinosima za obvezna
osiguranja) te<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.9pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>24. u stupcu 8. zbrojeni podaci pojedinačno iskazani
vodoravno, u stupcima 3. do 7. prema vrsti podatka iz stupca 2. Obrasca IDD-1.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.9pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span>(5) Podaci o
obvezniku plaćanja doprinosa pod II. upisuju se samo u slučaju kada je obveznik
plaćanja doprinosa osoba različita od obveznika obračunavanja odnosno podnositelja
izvješća.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.9pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span>(6) Obrazac
IDD-1 može se dostaviti ispisan putem računala, uz uvjet da sadržajem i oblikom
u cijelosti odgovara obrascu koji je propisan ovim Pravilnikom.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.9pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'><span style="mso-spacerun: yes"> </span>(7) Obrazac
IDD-1 potpisuje ovlaštena osoba podnositelja izvješća, koja pečatom i potpisom
jamči za istinitost i točnost iskazanih podataka.<o:p></o:p></span></p>

<p class=T-119sred><span style='font-size:12.0pt;mso-bidi-font-size:11.5pt'>6.
OBVEZE PRI ISPLATAMA PRIMITAKA NEREZIDENTIMA<o:p></o:p></span></p>

<p class=Clanak><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Članak
14.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(1)
Tuzemni isplatitelj primitaka obvezan je nerezidentima pri svakoj isplati
primitaka od kojih se utvrđuje dohodak prema članku 5. Zakona, obračunati,
obustaviti i uplatiti porez na dohodak u skladu s odredbama Zakona, ako ti
nerezidenti imaju prebivalište ili uobičajeno boravište u državama s kojima
Republika Hrvatska ne primjenjuje ugovor o izbjegavanju dvostrukog
oporezivanja.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.8pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) U slučaju iz stavka 1. ovoga članka, ispostava
Porezne uprave mjesno nadležna prema sjedištu isplatitelja na zahtjev
nerezidenta izdaje potvrdu o porezu na dohodak plaćenom u Republici Hrvatskoj.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.8pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(3) Tuzemni isplatitelj primitaka od kojih se
utvrđuje dohodak prema članku 5. Zakona, nerezidentima koji su rezidenti država
s kojima Republika Hrvatska primjenjuje ugovore o izbjegavanju dvostrukog
oporezivanja, obvezan je prilikom isplate obračunati, obustaviti i uplatiti
porez na dohodak na način određen ugovorom i tuzemnim Zakonom.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(4) Ako
Republika Hrvatska ima sa državom čiji je porezni obveznik rezident, sklopljen
ugovor o izbjegavanju dvostrukog oporezivanja, odredbe ugovora primjenjivat će
se na način propisan stavkom 5., 6., 7., 8., 9. i 10. ovoga članka.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(5)
Prava iz Ugovora ostvaruju se temeljem obrazaca, ovisno o vrsti isplate:<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>1.
»Zahtjev za umanjenje porezne obveze ili povrat više pla­ćenog poreza na
dividende prema Ugovoru o izbjegavanju dvostrukog oporezivanja između Republike
Hrvatske i —————«,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>2.
»Zahtjev za umanjenje porezne obveze, izuzimanje od porezne obveze ili povrat
više plaćenog poreza na kamate prema Ugovoru o izbjegavanju dvostrukog
oporezivanja između Republike Hrvatske i —————«,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>3.
»Zahtjev za umanjenje porezne obveze, izuzimanje od porezne obveze ili povrat
više plaćenog poreza na licence prema Ugovoru o izbjegavanju dvostrukog
oporezivanja između Republike Hrvatske i —————«,<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>4.
»Zahtjev za umanjenje porezne obveze, izuzimanje od porezne obveze ili povrat
više plaćenog poreza na naknade za djelatnost obavljenu u Republici Hrvatskoj
prema Ugovoru o izbjegavanju dvostrukog oporezivanja između Republike Hrvat­ske
i —————«.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(6) Za
primjenu odredbi iz Ugovora, obrazac »Zahtjev« treba biti ovjeren od nadležnog
inozemnog tijela. Ovjereni zahtjev se podnosi za svaku isplatu. Iznimno, ako se
radi o učestalim mjesečnim isplatama, ovjereni se zahtjev podnosi pri prvoj
isplati a potom ga je potrebno podnositi svakih šest (6) mjeseci.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:10.6pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(7) Obrasci iz stavka 5. ovoga članka sastoje se iz
četiri primjerka: primjerka za podnositelja zahtjeva, primjerka za
isplatitelja, primjerka za inozemno porezno tijelo i primjerka za Poreznu
upravu Republike Hrvatske. Odgovarajući obrazac podnositelj zahtjeva –
nerezident obvezan je ovjeriti pri poreznom tijelu države čiji je rezident.
Jedan primjerak obrasca namijenjen je inozemnom poreznom tijelu, drugi je
namijenjen podnositelju zahtjeva, a preostala dva primjerka ovjerenog obrasca s
popunjenim podacima o podnositelju zahtjeva, izjavom podnositelja zahtjeva, vrsti
djelatnosti, trajanju djelatnosti, predmetu ugovora, priloženim ispravama i
drugo, podnositelj zahtjeva dostavlja tuzemnom isplatitelju primitka. Tuzemni
isplatitelj pri isplati primitka jedan primjerak obrasca dostavlja Poreznoj
upravi, a drugi primjerak zadržava za svoje potrebe.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(8) Ako
tuzemni isplatitelj u trenutku isplate primitka nerezidentu raspolaže s
primjercima obrasca Zahtjeva iz stavka 5. ovoga članka, primijenit će
odgovarajuće odredbe ugovora o izbjegavanju dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(9) Ako
tuzemni isplatitelj u trenutku isplate primitka nerezidentu ne raspolaže
ovjerenim primjercima obrasca Zahtjeva iz stavka 5. ovoga članka, obvezan je
prilikom isplate primitka primijeniti odredbe tuzemnog zakona.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(10) U
slučaju iz stavka 9. ovoga članka nerezident može u roku od tri godine od
isteka godine u kojoj je primitak isplaćen, dostaviti Ministarstvu financija,
Poreznoj upravi, Područnom uredu Zagreb, ovjerovljeni obrazac Zahtjeva radi
povrata više plaćenog poreza u odnosu na porez koji je prema ugovoru o
izbjegavanju dvostrukog oporezivanja trebao biti plaćen.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(11)
Ministarstvo financija, Porezna uprava, Područni ured Zagreb, nadležan je i za
vođenje evidencije o postupanju po zahtjevima u slučajevima iz stavka 8. ovoga
članka.<o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>(12)
Obrasci zahtjeva iz stavka 5. ovoga članka sastavni su dio ovoga Pravilnika.<o:p></o:p></span></p>

<p class=T-119sred><span style='font-size:12.0pt;mso-bidi-font-size:11.5pt'>7.
PRIJELAZNE I ZAVRŠNE ODREDBE<o:p></o:p></span></p>

<p class=Clanak style='mso-line-height-alt:11.0pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>Članak 15.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:11.0pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(1) Do propisivanja oblika i sadržaja poslovnih
knjiga i evidencija, porezni obveznici vode poslovne knjige i sastavljaju
evidencije na obrascima oblikom i sadržajem propisanim ranije važećim
Pravilnikom o porezu na dohodak (»Narodne novine« broj 140/03, 188/03, 198/03 i
169/04), ako nisu u suprotnosti sa odredbama Zakona, osim obrazaca koji su
propisani ovim Pravil­nikom.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:11.0pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>(2) Za izvještajni mjesec prosinac 2004. i za
izvještajni mjesec siječanj 2005. podaci o primicima od nesamostalnog rada,
obračunanom porezu i prirezu te doprinosima za obvezna osiguranja popunjavaju
se i dostavljaju Poreznoj upravi na Obrascu ID propisanom člankom 19.
Pravilnika o porezu na dohodak (»Na­rod­ne novine«, broj 140/03, 188/03, 198/03
i 169/04).<o:p></o:p></span></p>

<p class=Clanak style='mso-line-height-alt:11.0pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>Članak 16.<o:p></o:p></span></p>

<p class=T-98-2 style='mso-line-height-alt:11.0pt'><span style='font-size:12.0pt;
mso-bidi-font-size:9.5pt'>Ovaj Pravilnik objavit će se u »Narodnim novinama« i
stupa na snagu 1. siječnja 2005. godine.<o:p></o:p></span></p>

<p class=Klasa2 style='margin-bottom:0cm;margin-bottom:.0001pt;mso-line-height-alt:
11.0pt'><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Klasa:
011-01/04-01/217<span style='mso-tab-count:4'>                                       </span><o:p></o:p></span></p>

<p class=Klasa2 style='margin-bottom:0cm;margin-bottom:.0001pt'><span style='font-size:12.0pt;mso-bidi-font-size:9.5pt'>Urbroj: 513-07-21-01/05-8<span style='mso-tab-count:4'>                                               </span>Zagreb,
3. siječnja 2005.<o:p></o:p></span></p>

<p class=Potpisnik><span lang=EN-GB>Ministar financija<br>
<b>Ivan Šuker, dipl. oec.,</b> v. r.</span></p>
<br><br>
<p class=MsoNormal>
<img src=dodatni/354372.gif><br>
<img src=dodatni/354373.gif><br>
<img src=dodatni/354374.gif><br>
<img src=dodatni/354375.gif><br>
<img src=dodatni/354376.gif></p>

<p class=MsoNormal><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></p>

<p class=MsoNormal><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></p>

<p class=MsoNormal><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></p>

<p class=MsoNormal><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>R
E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>PRIMJERAK
1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za podnositelja
zahtjeva -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY
1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX </span></b><b><span lang=EN-US style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>ADMINISTRATION</span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
EN-US'><span style="mso-spacerun:
yes">                                              </span>- for the claimant –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>DIVIDENDE </u>PREMA
UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX
RELIEF OR TAX REFUND FOR <u>DIVIDENDS </u>UNDER THE AGREEMENT FOR THE AVOIDANCE
OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND ……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>('Official
Gazette – International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 68.
Zakona o porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 39.
Zakona o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – </span><i><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
EN-US;font-weight:normal'>The data to be given in this application are
requested under Article 68 of Income Tax Act (&quot;Official Gazette&quot;,
number 177/04 ) and Article</span></i><i><span lang=EN-US style='font-size:
10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'> </span></i><i><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
EN-US;font-weight:normal'>39 of Profit Tax Act (&quot;Official Gazette&quot;,
number 177/04 )<o:p></o:p></span></i></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU DIVIDENDI –
  INFORMATION ON THE PAYER OF THE DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Business name: ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Matični broj – Tax number: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Sjedište – Address: …………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Poštanski broj – Postal code:
  ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU DIVIDENDI – INFORMATION ON
  THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECIPIENT OF THE
  DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormMsoNormal><b><span style='font-size;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– Full name / business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                              </span>Ulica i broj –
  Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Poštanski broj –
  Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Država – State:
  ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of the
  representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište /sjedište – Address: ………………………………………………………………………………….</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;mso-border-top-alt:
  solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;height:9.75pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">    </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Oblik dohotka – Form of income:
  a) dividende </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>– dividends: ……………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                              </span><span style="mso-spacerun: yes">                   </span>b) predujam –advance
  payment: …………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum isplate dividendi –Date of payment of the dividends:
  ………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos dividendi – Total amount of the dividends:
  ………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">     </span><span style="mso-spacerun: yes">      </span>Primjenjena stopa poreza – The tax
  rate applied: ……………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos poreza – Total amount of tax: ……………………………………………………………………</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-bottom:none;padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>IV.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>…………………………………………………………………………………………………………………………...<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:18.75pt'>
  <td width=588 valign=top style='width:441.0pt;border-top:solid windowtext 1.0pt;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;
  padding:0cm 5.4pt 0cm 5.4pt;height:18.75pt'>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:65.25pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:65.25pt'>
  <p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>V.<span style="mso-spacerun: yes">
  </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">       </span></span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>-
  In<span style="mso-spacerun: yes">  </span>the Republic of Croatia or in:
  ………………………………………………………………………<o:p></o:p></span></p>
  <pmsonormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Na broj računa – To the account number: …………………………………………………………………………..<o:p></o:p></span>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Kod (banka) – With the (bank): …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Otvorenog na ime – Opened in the name of: …………………………………………………….…………………<b><o:p></o:p></b></span></p>
  </pmsonormal></td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT
  OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span><span style="mso-spacerun:
  yes">  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>Potpisnik jamči da su gore navedeni podaci istiniti te da podnositelj
  zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>He
  is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Poznato mi je da Porezna uprava Republike Hrvatske može poreznom
  tijelu u državi rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>podnositelja zahtjeva davati podatke o sadržaju ovog zahtjeva – I am
  aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Croatian Tax Administration can disclose the information given in this
  Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Authorities in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext .5pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE
  REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation betwee between the Republic of
  Croatia…………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">    </span><o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='margin-left:18.0pt;text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>DIVIDENDE<o:p></o:p></b></span></p>

<p class=MsoNormal style='margin-left:2.25pt;text-align:justify'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza
na dividende osobi koja ima prebivalište, uobičajeno boravište ili sjedište
(rezidentu) u državi s kojom je Republika Hrvatska sklopila Ugovor o izbjegavanju
dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev za
umanjenje porezne obveze 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>DIVIDENDS<o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:20.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.7pt;text-align:justify;text-indent:
-.7pt'><span style='mso-ansi-language:HR;font-weight:normal'>1</span><span lang=EN-US style='font-weight:normal'>.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>This form is submitted for
tax relief or tax refund for dividends to a resident of the country with which
the Republic of Croatia entered into Agreement for the Avoidance of double
Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2</span><span lang=EN-US style='font-weight:normal'>.</span><span lang=EN-US style='mso-bidi-font-size:
7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span><span lang=EN-US style='font-weight:normal'>The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>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<span style="mso-spacerun: yes">  </span>the claimant,
items I and III by the payer of 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 remaining<span style="mso-spacerun:
yes">   </span>copies to the claimant (for the claimant, payer of the income,
and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>3.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nnbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;n><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>For each payer and for each payment a separate claim is made.<o:p></o:p></span></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.7pt;text-align:justify;text-indent:
-.7pt'><span lang=EN-US style='font-weight:normal'>4.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>Application for tax relief 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.<span style="mso-spacerun:
yes">               </span><o:p></o:p></span></p>

<p class=MsoNormal style='margin-left:2.25pt'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:12.0pt;mso-ansi-language:EN-US'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></b></p>

<p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">         </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes"> </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 2<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za isplatitelja dohotka
-<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun: yes">         </span><span style="mso-spacerun:
yes">                                                                       </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY 2<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                      </span>- for the payer of the income
–<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>DIVIDENDE </u>PREMA
UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX RELIEF
OR TAX REFUND FOR <u>DIVIDENDS </u>UNDER THE AGREEMENT FOR THE AVOIDANCE OF
DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND ……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>('Official
Gazette – International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 68.</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
EN-US;font-weight:normal'> Zakona o porezu na dohodak (&quot;Narodne
novine&quot;, broj 177/04) i članka 39. Zakona o porezu na dobit (&quot;Narodne
novine&quot;, broj 177/04) – <i>The data to be given in this application are
requested under Article 68 of Income Tax Act (&quot;Official Gazette&quot;, number
177/04) and Article 39 of Profit Tax Act (&quot;Official Gazette&quot;, number
177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU DIVIDENDI –
  INFORMATION ON THE PAYER OF THE DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Naziv tvrtke – Business name:
  ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Matični broj – Tax number:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Sjedište – Address:
  …………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                        </span>Ulica i broj –
  Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA TELJU DIVIDENDI – INFORMATION ON
  THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECIPIENT OF THE
  DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….<span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;mso-border-top-alt:
  solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;height:9.75pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">    </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Oblik dohotka – Form of income:
  a) dividende – dividends: ……………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">                   </span>b) predujam
  – advance payment: …………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Datum isplate dividendi –</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Date of payment of<span style="mso-spacerun: yes">  </span>the
  dividends: ………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos dividendi – Total amount of the dividends:
  ………………………………………………………</span><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span><span style="mso-spacerun:
  yes">        </span>Primjenjena stopa poreza – The tax rate applied:
  ……………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Ukupan iznos poreza – Total
  amount of tax: ……………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-bottom:none;padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>IV.<span style="mso-spacerun: yes">   </span>PRILOŽENI DOKUMENTI (broj i naziv) –
  Documents attached (number and title): </span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>…………………………………………………………………………………………………………………………...<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:18.75pt'>
  <td width=588 valign=top style='width:441.0pt;border-top:solid windowtext 1.0pt;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;
  padding:0cm 5.4pt 0cm 5.4pt;height:18.75pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:65.25pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:65.25pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun: yes">
  </span>the Republic of Croatia or in: ……………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Na broj računa – To the account number:
  …………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Kod (banka) – With the (bank):
  …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNorma style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Otvorenog na ime – Opened in the name
  of: …………………………………………………….…………………<b><o:p></o:p></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT
  OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span><span style="mso-spacerun:
  yes">    </span></span></b><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Potpisnik</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>jam</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>č</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>i</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>da</span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>su</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>gore</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>navedeni</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>podaci</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>istiniti</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>te</span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>da</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>podnositelj</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>zahtjeva</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>, </span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>naveden</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>pod</span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'> </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>to</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>č</span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>kom</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>II.,
  ispunjava sljedeće uvjete – The undersigned certifies that the beneficial
  owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – He is the beneficial owner of
  the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>kroz
  djelatnost registriranu u Republici Hrvatskoj – He did not derive income, as
  defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Poznato mi je da Porezna uprava Republike Hrvatske može poreznom
  tijelu u državi rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>podnositelja zahtjeva davati podatke o sadržaju ovog zahtjeva – I am
  aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Croatian Tax Administration can disclose the information given in this
  Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Authorities in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext .5pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE
  REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">    </span><o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>DIVIDENDE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza
na dividende osobi koja ima prebivalište, uobičajeno boravište ili sjedište
(rezidentu) u državi s kojom je Republika Hrvatska sklopila Ugovor o izbjegavanju
dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev za
umanjenje porezne obveze 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>DIVIDENDS<o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:20.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>1.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>This form is submitted for
tax relief or tax refund for dividends to a residentesident of the country with which
ublic of Croatia entered into Agreement for the Avoidance of double
Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>2.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>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 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
remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for
the claimant, payer of the income, and the Tax Administration of the Republic
of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>3.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>For each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>4.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>Application for tax relief 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.<span style="mso-spacerun:
yes">               </span><o:p></o:p></span></p>

<p class=MsoNormal style='margin-left:2.25pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></b></p>

<p class=T-98-2><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=T-98-2><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun: yes">
</span>- za poreznu upravu Republike Hrvatske -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun: yes">   </span><span style="mso-spacerun:
yes">                                                                             </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY 3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>- for the Tax Administration of the Republic of Croatia –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>DIVIDENDE </u>PREMA
UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX RELIEF
OR TAX REFUND FOR <u>DIVIDENDS </u>UNDER THE AGREEMENT FOR THE AVOIDANCE OF
DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND ……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt:10.0pt;
mso-bidi-font-size:8.0pt;ight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>68. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 39. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 68 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04) and Article 39 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU DIVIDENDI –
  INFORMATION ON THE PAYER OF THE DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Naziv tvrtke – Business name:
  ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Matični broj – Tax number:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Sjedište – Address:
  …………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                        </span>Ulica i broj –
  Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU DIVIDENDI – INFORMATION ON
  THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECIPIENT OF THE
  DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….<span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;mso-border-top-alt:
  solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;height:9.75pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">    </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Oblik dohotka – Form of income:
  a) dividende – dividends: ……………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">                   </span>b) predujam
  – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
  mso-ansi-language:EN-US'>advance payment: …………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;ms.0pt;mso-bidi-font-size:
  8.0pt;m-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum isplate dividendi –Date of payment of the dividends:
  ………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos dividendi – Total amount of the dividends:
  ………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">    </span><span style="mso-spacerun: yes">       </span>Primjenjena stopa poreza – The tax
  rate applied: ……………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos poreza – Total amount of tax: ……………………………………………………………………</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-bottom:none;padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>IV.<span style="mso-spacerun: yes">   </span>PRILOŽENI DOKUMENTI (broj i naziv) –
  Documents attached (number and title): </span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>…………………………………………………………………………………………………………………………...<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:18.75pt'>
  <td width=588 valign=top style='width:441.0pt;border-top:solid windowtext 1.0pt;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;
  padding:0cm 5.4pt 0cm 5.4pt;height:18.75pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:65.25pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:65.25pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun: yes">
  </span>the Republic of Croatia or in: ……………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Na broj računa – To the account number:
  …………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Kod (banka) – With the (bank):
  …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Otvorenog na ime – Opened in the name
  of: …………………………………………………….…………………<b><o:p></o:p></b></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT
  OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span><span style="mso-spacerun:
  yes">   </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>Potpisnik jamči da su gore navedeni podaci istiniti te da podnositelj
  zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>–
  He is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj
  – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
  mso-ansi-language:EN-US'>He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Poznato mi je da Porezna uprava Republike Hrvatske može poreznom
  tijelu u državi rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>podnositelja zahtjeva davati podatke
  o sadržaju ovog zahtjeva </span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>– I am aware of<span style="mso-spacerun: yes">  </span>the an>the fact that the <o:p></o:p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Croatian Tax Administration can disclose the information given in this
  Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">   </span><span style="mso-spacerun: yes">     </span>Authorities in the country of residence
  of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </span></p></td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext .5pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE
  REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span><span style="mso-spacerun:
  yes">  </span>dvostrukog oporezivanja između Republike Hrvatske i …………………… -
  The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span><o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext .5pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:57.8pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:57.8pt'>
  <p class=MsoNormal style='margin-left:21.6pt;text-indent:-21.6pt'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VIII. NAPOMENE POREZNE
  UPRAVE REPUBLIKE HRVATSKE (ako ih ima) – CROATIAN TAX AUTHORITIES REMARKS (if
  any)<o:p></o:p></span></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>DIVIDENDE<o:p></o:p></b></span></p>

<p class=MsoNormal style='margin-left:2.25pt;text-align:justify'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza
na dividende osobi koja ima prebivalište, uobičajeno boravište ili sjedište
(rezidentu) u državi s kojom je Republika Hrvatska sklopila Ugovor o
izbjegavanju dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='style=' mso-ansi-language:hr;font-wermal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev za
umanjenje porezne obveze 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>DIVIDENDS<o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:20.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>1.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>This form is submitted for
tax relief or tax refund for dividends to a resident of the country with which
the Republic of Croatia entered into Agreement for the Avoidance of double
Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>2.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>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 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
remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for
the claimant, payer of the income, and the Tax Administration of the Republic
of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>3.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>For each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>4.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>Application for tax relief 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</span><span style='mso-ansi-language:
HR;font-weight:normal'>.<span style="mso-spacerun: yes">               </span><o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun: yes">                             </span><span style="mso-spacerun: yes">         </span>- za inozemno porezno tijelo -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY
4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                    </span>- for the foreign tax authority
–<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>DIVIDENDE </u>PREMA
UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX RELIEF
OR TAX REFUND FOR <u>DIVIDENDS </u>UNDER THE AGREEMENT FOR THE AVOIDANCE OF
DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND ……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-languageanguage:HR;
font-weight:normal'> <span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>68. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 39. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 68 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04) and Article 39 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU DIVIDENDI –
  INFORMATION ON THE PAYER OF THE DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Naziv tvrtke – Business name:
  ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Matični broj – Tax number:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Sjedište – Address:
  …………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                        </span>Ulica i broj –
  Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU DIVIDENDI – INFORMATION ON
  THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECIPIENT OF THE
  DIVIDENDS:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….<span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;mso-border-top-alt:
  solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;height:9.75pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yerun: yes">    </span>PODACI O DOHOESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Oblik dohotka – Form of income:
  a) dividende – dividends: ……………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">                   </span>b) predujam
  –advance payment: …………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Datum isplate dividendi –Date of
  payment of<span style="mso-spacerun: yes">  </span>the dividends:
  ………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Ukupan iznos dividendi – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Total amount of the dividends: ………………………………………………………</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span><span style="mso-spacerun:
  yes">       </span>Primjenjena stopa poreza – The tax rate applied:
  ……………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Ukupan iznos poreza – Total
  amount of tax: ……………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-bottom:none;padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>IV.<span style="mso-spacerun: yes">   </span>PRILOŽENI DOKUMENTI (broj i naziv) –
  Documents attached (number and title): </span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>…………………………………………………………………………………………………………………………...<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:18.75pt'>
  <td width=588 valign=top style='width:441.0pt;border-top:solid windowtext 1.0pt;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;
  padding:0cm 5.4pt 0cm 5.4pt;height:18.75pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:65.25pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:65.25pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun: yes">
  </span>the Republic of Croatia or in: ……………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Na broj računa – To the account number:
  …………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Kod (banka) – With the (bank):
  …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Otvorenog na ime – Opened in the name
  of: …………………………………………………….…………………<b><o:p></o:p></b></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT
  OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span><span style="mso-spacerun:
  yes">   </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>Potpisnik jamči da su gore navedeni podaci istiniti te da podnositelj
  zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>–
  He is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered inered in the Republic of Croatia, <op></op></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Poznato mi je da Porezna uprava Republike Hrvatske može poreznom
  tijelu u državi rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>podnositelja zahtjeva davati podatke
  o sadržaju ovog zahtjeva </span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>– I am aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Croatian Tax Administration can disclose the information given in this
  Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Authorities in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:14.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext .5pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:63.0pt'>
  <td width=564 valign=top style='width:423.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:63.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE
  REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">    </span><o:p></o:p></span></b></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>DIVIDENDE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza
na dividende osobi koja ima prebivalište, uobičajeno boravište ili sjedište
(rezidentu) u državi s kojom je Republika Hrvatska sklopila Ugovor o izbjegavanju
dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
svakog
isplatitelja i za svaku ispdnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev za
umanjenje porezne obveze 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>DIVIDENDS<o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:20.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>1.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>This form is submitted for
tax relief or tax refund for dividends to a resident of the country with which
the Republic of Croatia entered into Agreement for the Avoidance of double
Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>2.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>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 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
remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for
the claimant, payer of the income, and the Tax Administration of the Republic
of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>3.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>For each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>4.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>Application for tax relief 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.<span style="mso-spacerun:
yes">    </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">     </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span></span><b><span style='font-size:
10.0pt;mso-bidi-font-size:8.0pt'>R E P U B L I K A<span style="mso-spacerun:
yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>PRIMJERAK
1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za podnositelja
zahtjeva -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun: yes">
</span><span style="mso-spacerun:
yes">                                                                     </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY 1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                                </span>- for the claimant
–<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>KAMATE</u>
I<span style="mso-spacerun: yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O
IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:centen:center'><b><span style='font-sizt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX
RELIEF, TAX EXEMPTION OR TAX REFUND FOR <u>INTEREST</u> UNDER THE AGREEMENT FOR
THE AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>30. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 30 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04) and Article 31 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU KAMATE –
  INFORMATION ON THE PAYER OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Full name / business name: ……………………………..…………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj (MBG ili matični broj) – Number (identification number / tax
  number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">           </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU KAMATE – INFORMATION ON THE<span style="mso-spacerun: yes">                     </span><span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECEPIENT OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– Full name / business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-s=" mso-spacerun: yes">
  <o:p></o:p></span></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                              </span>Ulica i broj –
  Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Poštanski broj –
  Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Država – State:
  ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of the
  representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">    </span><span style="mso-spacerun: yes">      </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">    </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt;
  font-weight:normal'><span style="mso-spacerun: yes">           </span>Temelj
  isplate – Payment basis: …………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Datum izdavanja ili sklapanja
  ugovora </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>– Date of issue or conclusion of the contract:
  …………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan uznos kamate – Total amount of interest:
  ………………………..……………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum isplate<span style="mso-spacerun: yes">  </span>– Date of
  payment : …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos poreza – Total amount of tax: …………………………………………………………………..</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span>IV.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>…………………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span>V.<span style="mso-spacerun: yes">
  </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span><span style="mso-spacerun:
  yes">      </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span></span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>- In<span style="mso-spacerun: yes">  </span>the Republic of Croatia
  or in: …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Na broj računa – To the account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Kod (banka) – With the (Bank): …………………………………………………………………<span style="mso-spacerun: yes">                    </span><span style="mso-spacerun:
  yes">                                              </span><o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Otvorenog na ime – Opened in the name of:</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> …………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>VI.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='fonle=' font-size:10.0pt;mso-bidi-font-0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>–
  He is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poznato
  mi je da Porezna uprava Republike Hrvatske može poreznom tijelu u državi
  rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>podnositelja zahtjeva davati podatke o sadržaju
  ovog zahtjeva – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>I am aware of<span style="mso-spacerun: yes">
  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Croatian
  Tax Administration can disclose the information given in this Application to
  the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Authorities in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>VII.<span style="mso-spacerun:
  yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - </span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>The claimant is the
  resident <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>of …………………. Under Article ……………………….. of the Agreement for the
  avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>taxation between the Republic of Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>KAMATE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-pt;mso-ansi-language:HR;font-weight'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na kamate osobi koja ima
prebivalište, uobičajeno boravište ili sjedište (rezidentu) u državi s kojom je
Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:17.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>INTERESTS<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>1.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>This form is submitted for
tax relief, tax exemption or tax refund for interest to a resident of the
country with which the Republic of Croatia entered into Agreement for the
Avoidance of double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>2.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>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 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 </span><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>control, certify
a submitted form, and retain their own copy, and return the remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for the claimant,
payer of the income, and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>For each payer and for each payment a
separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>Application 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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span lang=EN-US style='font-weight:normal'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">   </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span></span><b><span style='font-size:
10.0pt;mso-bidi-font-size:8.0pt'>R E P U B L I K A<span style="mso-spacerun:
yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>PRIMJERAK
2<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za isplatitelja dohotka
-<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY
2<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                        </span>- for the payer of the
income –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>KAMATE</u>
I<span style="mso-spacerun: yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O
IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX
RELIEF, TAX EXEMPTION OR TAX REFUND FOR <u>INTEREST</u> UNDER THE AGREEMENT FOR
THE AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 30.
Zakona o porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31.
Zakona o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The
data to be given in this application are requested under Article 30 of Income
Tax Act (&quot;Official Gazette&quot;, number 177/04) and Article 31 of Profit
Tax Act (&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU KAMATE –
  INFORMATION ON THE PAYER OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– Full name / business name: ……………………………..…………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj (MBG ili matični broj) – Number (identification number / tax
  number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">           </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU KAMATE – INFORMATION ON THE<span style="mso-spacerun: yes">                     </span><span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECEPIENT OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Full name / business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………..<o:p></o:p></span></p>

  <p class=MsoNormal><span las style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                              </span>Ulica i broj –
  Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Poštanski broj –
  Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Država – State:
  ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of the
  representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">    </span><span style="mso-spacerun: yes">      </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">    </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt;
  font-weight:normal'><span style="mso-spacerun: yes">           </span>Temelj
  isplate – Payment basis: …………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum izdavanja ili sklapanja ugovora – Date of issue or conclusion of
  the contract: …………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan uznos kamate – Total amount of interest:
  ………………………..……………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum isplate<span style="mso-spacerun: yes">  </span>– Date of
  payment : …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos poreza – Total amount of tax: …………………………………………………………………..</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span>IV.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>…………………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span>V.<span style="mso-spacerun: yes">
  </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span><span style="mso-spacerun:
  yes">      </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>-
  In<span style="mso-spacerun: yes">  </span>the Republic of Croatia or in:
  …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Na broj računa – To the
  account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (Bank): …………………………………………………………………<span style="mso-spacerun:
  yes">                    </span><span style="mso-spacerun:
  yes">                                              </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: …………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>VI.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p></p><p class=MsoNormal><b><span style='ze:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:35.25pt;text-indent:-18.0pt;mso-list:
  l3 level1 lfo35;tab-stops:list 35.25pt'><![if !supportLists]><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>1.<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  </span></span><![endif]><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>&nbsp;&nbsp;Stvarni je korisnik gore navedenog dohotka </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– He is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:35.25pt;text-indent:-18.0pt;mso-list:
  l3 level1 lfo35;tab-stops:list 35.25pt'><![if !supportLists]><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>2.<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  </span></span><![endif]><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog
  oporezivanja nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj
  – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
  mso-ansi-language:EN-US'>He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Poznato mi je da Porezna uprava
  Republike Hrvatske može poreznom tijelu u državi rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>podnositelja zahtjeva davati podatke
  o sadržaju ovog zahtjeva </span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>– I am aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Croatian Tax Administration can disclose the information given in this
  Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Authorities in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">                  </span><span style="mso-spacerun: yes">                   </span>Potpis – Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>VII.<span style="mso-spacerun:
  yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - </span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>The claimant is the
  resident <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>of …………………. Under Article ……………………….. of the Agreement for the
  avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>taxation between the Republic of Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Stamp<span style="mso-spacerun: yes">    </span></span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">                                        </span>Potpis – Signatur/o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='margin-left:17.25pt;text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>KAMATE<o:p></o:p></b></span></p>

<p class=MsoNormal style='margin-left:2.25pt;text-align:justify'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na kamate osobi koja ima
prebivalište, uobičajeno boravište ili sjedište (rezidentu) u državi s kojom je
Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:17.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>INTERESTS<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>1.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>This form is submitted for
tax relief, tax exemption or tax refund for interest to a resident of the
country with which the Republic of Croatia entered into Agreement for the
Avoidance of double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2</span><span lang=EN-US style='font-weight:normal'>.</span><span lang=EN-US style='mso-bidi-font-size:
7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span lang=EN-US style='font-weight:normal'>The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>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 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
remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for
the claimant, payer of the income, and the Tax Administration of the Republic
of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3</span><span lang=EN-US style='font-weight:normal'>.</span><span lang=EN-US style='mso-bidi-font-size:
7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun: yes"> </span>For
each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>4.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'><span style="mso-spacerun:
yes"> </span>Application for tax relief, tax exemption or tax refund is
submitted to the Ministry of finance of the Republic of Croatia, Tax
adTax
administration, Zagreb office,a Dubrovnik 32, at latest within 3 years
as of expiry of the calendar year in which the payment is effected. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">     </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">         </span></span><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes"> </span><b>R E P U B
L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun: yes">                              </span>-
za Poreznu upravu Republike Hrvatske - <o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span><b><span style="mso-spacerun:
yes"> </span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></b>COPY 3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>- </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:EN-US'>for the Tax Administration of the Republic of Croatia
–</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>KAMATE</u>
I<span style="mso-spacerun: yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O
IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX
RELIEF, TAX EXEMPTION OR TAX REFUND FOR INTEREST UNDER THE AGREEMENT FOR THE
AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND </span><span lang=EN-US style='mso-bidi-font-size:8.0pt'>……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>('Official
Gazette – International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 30.
Zakona o porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31.
Zakona o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – </span><i><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
EN-US;font-weight:normal'>The data to be given in this application are
requested under Article 30 of Income Tax Act (&quot;Official Gazette&quot;,
number </span></i><i><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;font-weight:normal'>177/04</span></i><i><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US;
font-weight:normal'>) and Article 31 of Profit Tax Act (&quot;Official
Gazette&quot;, number </span></i><i><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>177/04</span></i><i><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
EN-US;font-weight:normal'>)<o:p></o:p></span></i></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 colspan=2 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU KAMATE –
  INFORMATION ON THE PAYER OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Full name / business name: ……………………………..…………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj (MBG ili matični broj) – Number (identification number / tax
  number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">           </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:124.5pt;mso-row-margin-right:.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:124.5pt'>
  <'>
  <p class=MsoNormal><span styl-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU KAMATE – INFORMATION ON THE<span style="mso-spacerun: yes">                      </span><span style="mso-spacerun: yes">    </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECEPIENT OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span><span style="mso-spacerun:
  yes">     </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….<span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
  <td style='mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm' width=1><p class='MsoNormal'>&nbsp;</p></td>
 </tr>
 <tr style='height:44.65pt;mso-row-margin-right:.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;III.<span style="mso-spacerun: yes">    </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt;
  font-weight:normal'><span style="mso-spacerun: yes">           </span>Temelj
  isplate – Payment basis: …………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum izdavanja ili sklapanja ugovora – Date of issue or conclusion of
  the contract: …………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan uznos kamate – Total amount of interest:
  ………………………..……………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum isplate<span style="mso-spacerun: yes">  </span>– Date of
  payment : …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos poreza – Total amount of tax:</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>
  …………………………………………………………………..<o:p></o:p></span></p>
  </td>
  <td style='mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm' width=1><p class='MsoNormal'>&nbsp;</p></td>
 </tr>
 <tr style='height:25.5pt;mso-row-margin-right:.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">  </span>IV.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </b>…………………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
  <td style='mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm' width=1><p class='MsoNormal'>&nbsp;</p></td>
 </tr>
 <tr style='height:25.5pt;mso-row-margin-right:.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">   </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">            </span><span style="mso-spacerun:
  yes">   </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>-
  In<span style="mso-spacerun: yes">  </span>the Republic of Croatia or in:
  …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Na broj računa – To the
  account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (Bank): …………………………………………………………………<span style="mso-spacerun:
  yes">                       </span><span style="mso-spacerun:
  yes">                                           </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: …………………………………………………….<o:p></o:p></span></p>
  </td>
  <td style='mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm' width=1><p class='MsoNormal'>&nbsp;</p></td>
 </tr>
 <tr style='height:25.5pt;mso-row-margin-right:.75pt'>
5pt'>
  <td width=588 valign=top sidth:441.0pt;border:solid windowtext 1.0pt; border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt; height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>VI.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>He
  is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj
  – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
  mso-ansi-language:EN-US'>He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Poznato mi je da Porezna uprava Republike Hrvatske može poreznom
  tijelu u državi rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>podnositelja zahtjeva davati podatke
  o sadržaju ovog zahtjeva </span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>– I am aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Croatian Tax Administration can disclose the information given in this
  Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Authorities in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">                  </span><span style="mso-spacerun: yes">                   </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
  <td style='mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm' width=1><p class='MsoNormal'>&nbsp;</p></td>
 </tr>
 <tr style='height:25.5pt;mso-row-margin-right:.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">        </span>VII.<span style="mso-spacerun:
  yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - </span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>The claimant is the
  resident <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>of …………………. Under Article ……………………….. of the Agreement for the
  avoidance of double <o:p></o:p></span></p>
  <p class=Mslass=MsoNormal><span lang=EN-US styt-size:10.0pt;mso-bidi-font-size: 8.0pt;mso-ansi-language:en-us'><span style="mso-spacerun: yes">
  </span>taxation between the Republic of Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
  <td style='mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm' width=1><p class='MsoNormal'>&nbsp;</p></td>
 </tr>
 <tr style='height:18.1pt;mso-row-margin-right:.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:18.1pt'>
  <p class=MsoNormal style='margin-left:21.6pt;text-indent:-21.6pt'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">       </span>VIII. NAPOMENE POREZNE UPRAVE
  REPUBLIKE HRVATSKE (ako ih ima) – CROATIAN TAX AUTHORITIES REMARKS (if any)<o:p></o:p></b></span></p>
  </td>
  <td style='mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm' width=1><p class='MsoNormal'>&nbsp;</p></td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>KAMATE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na kamate osobi koja ima
prebivalište, uobičajeno boravište ili sjedište (rezidentu) u državi s kojom je
Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:17.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>INTERESTS<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1</span><span lang=EN-US style='font-weight:normal'>.</span><span lang=EN-US style='mso-bidi-font-size:
7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span lang=EN-US style='font-weight:normal'>This form is submitted for tax relief,
tax exemption or tax refund for interest to a resident of the country with
which the Republic of Croatia entered into Agreement for the Avoidance of
double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>2.</span><span lang=EN-US style='mso-bidi-font-size:7.0pt;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='font-weight:normal'>The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='font-weight:normal'>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 income,
and the item VII by the foreign tax authority. The filled in and signed copies
of the </span><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:
normal'>form are submitted to the tax authorities of the country in which the
r the
recipient is resident. Foreiguthorities shall carry out the required
control, certify a submitted form, and retain their own copy, and return the
remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for
the claimant, payer of the income, and the Tax Administration of the Republic
of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>For each payer and for each payment a
separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>Application 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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><span style="mso-spacerun: yes">              </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun:
yes">   </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">                                               </span><span style="mso-spacerun: yes">                       </span></b>PRIMJERAK 4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za inozemno porezno
tijelo -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span><span style="mso-spacerun: yes">      </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY 4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                        </span></span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>- for
the foreign tax authority –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA <u>KAMATE</u>
I<span style="mso-spacerun: yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O
IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX
RELIEF, TAX EXEMPTION OR TAX REFUND FOR <u>INTEREST</u> UNDER THE AGREEMENT FOR
THE AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>30. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 30 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04) and Article 31 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<p class=MsoNormal><spa='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></spa='font-size:10.0pt;mso-bidi-font-size:12.0pt'></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU KAMATE –
  INFORMATION ON THE PAYER OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Full name / business name: ……………………………..…………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj (MBG ili matični broj) – Number (identification number / tax
  number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">           </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU KAMATE – INFORMATION ON THE<span style="mso-spacerun: yes">                     </span><span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECEPIENT OF THE INTEREST:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name / </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                              </span>Ulica i broj –
  Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Poštanski broj –
  Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Država – State:
  ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of the
  representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">    </span><span style="mso-spacerun: yes">      </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">    </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt;
  font-weight:normal'><span style="mso-spacerun: yes">           </span>Temelj
  isplate – Payment basis: …………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum izdavanja ili sklapanja ugovora – Date of issue or conclusion of
  the contract: …………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US stylus style='font-size:10.0pt;mso-bidiize:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan uznos kamate – Total amount of interest:
  ………………………..……………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Datum isplate<span style="mso-spacerun: yes">  </span>– Date of
  payment : …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ukupan iznos poreza – Total amount of tax: …………………………………………………………………..</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span>IV.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>…………………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span>V.<span style="mso-spacerun: yes">
  </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span><span style="mso-spacerun:
  yes">      </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>-
  In<span style="mso-spacerun: yes">  </span>the Republic of Croatia or in:
  …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Na broj računa – To the
  account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (Bank): …………………………………………………………………<span style="mso-spacerun:
  yes">                    </span><span style="mso-spacerun:
  yes">                                              </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: …………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>VI.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>He
  is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj
  – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
  mso-ansi-language:EN-US'>He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poznato
  mi je da Porezna uprava Republike Hrvatske može poreznom tijelu u državi
  rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>podnositelja zahtjeva davati podatke o sadržaju
  ovog zahtjeva – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>I am aware of<span style="mso-spacerun: yes">
  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Croatian
  Tax Administration can disclose the information given in this Application to
  the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span lang=EN-US style='font-size:10.0pt;mso-pt;mso-bidi-font-size:8.0pt;mso-ansage:EN-US'>Authorities
  in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>VII.<span style="mso-spacerun:
  yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>KAMATE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na kamate osobi koja ima
prebivalište, uobičajeno boravište ili sjedište (rezidentu) u državi s kojom je
Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:17.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-laHR'>INTERESTS<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>1</span><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
This form is submitted for tax relief, tax exemption or tax refund for interest
to a resident of the country with which the Republic of Croatia entered into
Agreement for the Avoidance of double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
The 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<span style="mso-spacerun:
yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>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 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 remaining<span style="mso-spacerun:
yes">   </span>copies to the claimant (for the claimant, payer of the income,
and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>For each payer and for each payment a
separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>Application 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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;R
E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>PRIMJERAK
1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za podnositelja zahtjeva
-<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY
1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                                </span>- for the claimant–<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA
LICENCE<span style="mso-spacerun: yes">  </span>I<span style="mso-spacerun:
yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>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
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci iz ovog Zahtjeva potrebni su zbog primjene članka 27.
Zakona o porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31.
Zakona o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The
data to be given in this application are requested under Article 27 of Income
Tax Act (&quot;Official Gazette&quot;, number 177/04 ) and Article 31 of Profit
Tax Act (&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O STJECATELJU LICENCE –
  INFORMATION ON THE LICENSEE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span span style="mso-spacerun: yes"> span>Ime i prezime / naziv tvrtke </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– Full name / business name: ……………………………..…………………………<o:p></o:p></span></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">     </span><span style="mso-spacerun: yes"> </span>Broj (MBG ili matični broj) – Number (identification
  number / tax number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Zanimanje / djelatnost – Occupation: …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Poštanski broj – Postal code:
  ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – DAVATELJU LICENCE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – LICENSOR:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;</span></b><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span></span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Zanimanje / djelatnost – Occupation: …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                   </span><span style="mso-spacerun:
  yes">           </span>Ulica i broj – Street and number:
  ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Poštanski broj –
  Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Država – State:
  ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of the
  representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište /sjedište – Address. ………………………………………………………………………………….</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;border-bottom:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:9.75pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:115.85pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:115.85pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">  </span>PREDMET UGOVORA O LICENCI – SUBJECT MATTER
  OF LICENCE:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>3.1.&nbsp;&nbsp; Prava intelektualnog
  vlasništva – Intelectual property rights<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste prava intelektualnog vlasništva – Form of intellectual property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>…………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>……………………………………………………………………………………………………………………………<o:p>/span></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Registracija prava intelektualnog vlasništva – Registration of intellectual
  property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Država registracije –
  Country of registration: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Broj registracije –
  Registration number: ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Datum registracije – Date
  of registration: ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Nositelj prava intelektualnog vlasništva prema registru – Registered owner of
  intellectual property right:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ime
  i prezime / naziv tvrtke – Full name / business name: …………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Pravni
  oblik – Legal form: ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Zanimanje
  / djelatnost – Occupation: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prebivalište
  / sjedište – Address: …………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ulica
  i broj – Street and number: …………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poštanski
  broj – Postal code: ………………….<span style="mso-spacerun: yes">
  </span>Grad – City: ……………………….…<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Država
  – State: ………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.2.</span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>&nbsp;&nbsp; <b>Prava na korištenje pokretnina</b> ( između ostalog
  leasing – ugovori) -<span style="mso-spacerun: yes">  </span>Right to use
  movable property <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>(under
  a leasing or another agreement)<span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">                </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.2.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste pokretnina – Type of movable property:</span><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'> ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>………………………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>3.3.</span></b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;&nbsp; <b>Autorska prava</b> (prava koja ne
  spadaju pod točku 3.1.) – </span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Copyrights (other than
  those under paragraph 3.1.)<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3..3.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste autorskog prava – Form of copyright: ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3..3.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Naziv zaštićenog dijela – Title of protected work: ………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3..3.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Autor – Author<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ime
  – Name: ……………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prezime
  – Surname: ……………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prebivalište
  / sjedište – Address: <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ulica
  i broj – Street and number: …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poštanski
  broj – Postal code: ………………………..Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Država
  – State: …………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Davatelj
  licence ovlašten je za davanje licence na temelju – The licensor is
  authorized to grant licence by virtue of:
  ……………………………………………………………………………………………. <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>IV.<span style="mso-spacerun: yes">  </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNorme='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                </span>Ukupan iznos dohotka – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Total amount of income: ………………………..………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                </span>Datum isplate – Date of payment:
  ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                </span>Ukupan iznos poreza – Total amount of tax:</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'> ………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span></span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>PRILOŽENI DOKUMENTI (broj i naziv) –
  Documents attached (number and title):<span style="mso-spacerun: yes">
  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili
  u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun:
  yes">  </span>the Republic of Croatia or in: …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Na broj računa – To the
  account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (Bank): …………………………………………………………………<span style="mso-spacerun:
  yes">
  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span><span style="mso-spacerun:
  yes">            </span>Otvorenog na ime – Opened in the name of:
  …………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoBodyText3 style='tab-stops:12.6pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci istiniti
  te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun:
  yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>II., ispunjava sljedeće uvjete </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>under
  II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>He
  is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Dohodak
  u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja nije
  ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the activity
  registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poznato
  mi je da Porezna uprava Republike Hrvatske može poreznom tijelu u državi
  rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>podnositelja
  zahtjeva davati podatke o sadržaju ovog zahtjeva – I am aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Croatian
  Tax Administration can disclose the information given in this Application to
  the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;ms.0pt;mso-bidi-font-size:8.0pt;mso-aguage:EN-US'>Authorities
  in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VIII.
  POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>UPUTA ZA POPUNJAVANJE: <b>LICENCE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Ovaj obrazac podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja
porezne obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Obrazac 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, VI i
VII popunjava podnositelj zahtjeva, točke I i III popunjava isplatitelj, a
točku VIII 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Za svakog isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyTele='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS
FOR FILLING IN THE FORM: </span><span style='mso-bidi-font-size:8.0pt;
mso-ansi-language:HR'>ROYALTIES<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
This 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Tax
Administration of the Republic of Croatia, and the forth copy for the foreign
tax authority. Items II, IV, V, VI and VII are to be filled in by the claimant,
items I and III by the payer of income, and the item VIII 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 remaining<span style="mso-spacerun:
yes">   </span>copies to the claimant (for the claimant, payer of the income,
and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>For each payer and for each payment a
separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>Application 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. <o:p></o:p></span></p>

<p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
12.0pt;mso-ansi-language:EN-US'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></b></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 2<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za isplatitelja dohotka
-<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF </span></b><b><span lang=EN-US style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:EN-US'>COPY 2<o:p></o:p></span></p>

<p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:EN-US'>MINISTRY OF FINANCE-TAX ADMINISTRATION</span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
EN-US'><span style="mso-spacerun: yes">                      </span><span style="mso-spacerun: yes">                 </span>- for the payer of the income
–<o:p></o:p></span></p>

<p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:EN-US'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA
LICENCE<span style="mso-spacerun: yes">  </span>I<span style="mso-spacerun:
yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p>

<p class=MsoNormal align=cente='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>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
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>27. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 27 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04 ) and Article 31 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O STJECATELJU LICENCE –
  INFORMATION ON THE LICENSEE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Ime i prezime / naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Full name / business name: ……………………………..…………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj (MBG ili matični broj) – Number (identification number / tax
  number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Zanimanje / djelatnost – Occupation: …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Poštanski broj – Postal code:
  ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – DAVATELJU LICENCE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – LICENSOR:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Full name / business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span></span><span lang=EN-US style='font-size:1so-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Zanimanje / djelatnost – Occupation: …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                              </span><span style="mso-spacerun:
  yes">                </span>Ulica i broj – Street and number:
  ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Poštanski broj –
  Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Država – State:
  ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of the
  representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište /sjedište – Address. ………………………………………………………………………………….</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;border-bottom:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:9.75pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:115.85pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:115.85pt'>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>PREDMET UGOVORA O LICENCI – SUBJECT MATTER
  OF LICENCE:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:20.25pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>3.1.&nbsp;&nbsp; Prava intelektualnog
  vlasništva – Intelectual property rights<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste prava intelektualnog vlasništva – Form of intellectual property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>…………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>…………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Registracija prava intelektualnog vlasništva – Registration of intellectual
  property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Država registracije –
  Country of registration: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Broj registracije –
  Registration number: ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Datum registracije – Date
  of registration: ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Nositelj prava intelektualnog vlasništva prema registru – Registered owner of
  intellectual property right:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name / business
  name: …………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Pravni oblik – Legal form:
  ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Zanimanje / djelatnost – Occupation:
  ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Prebivalište / sjedište – Address:
  …………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Ulica i broj – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Street
  and number: …………………………………………………………….</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Poštanski broj – Postal code: ………………….<span style="mso-spacerun: yes">        </span>Grad – City: ……………………….…<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>Država – State: ………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></b></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>3.2.</span></b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;&nbsp; <b>Prava na korištenje </b></span><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>pokretnina</span></b><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'> ( između ostalog leasing –
  ugovori) -<span style="mso-spacerun: yes">  </span>Right to use movable
  property <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>(under
  a leasing or another agreement)<span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes">               </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US sts style='font-size:10.0pt;mso-bi-size:8.0pt;mso-ansi-language:EN-US'>3.2.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste pokretnina – Type of movable property:</span><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'> ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>………………………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>3.3.</span></b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;&nbsp; <b>Autorska prava</b> (prava koja ne
  spadaju pod točku 3.1</span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>.) – Copyrights (other than
  those under paragraph 3.1.)<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste autorskog prava – Form of copyright: ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Naziv zaštićenog dijela – Title of protected work: ………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Autor – Author<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ime
  – Name: ……………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prezime
  – Surname: ……………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prebivalište
  / sjedište – Address: <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ulica
  i broj – Street and number: …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poštanski
  broj – Postal code: ………………………..Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Država
  – State: …………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Davatelj
  licence ovlašten je za davanje licence na temelju – The licensor is
  authorized to grant licence by virtue of:
  ……………………………………………………………………………………………. <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt;text-indent:2.25pt'><![if !supportEmptyParas]>&nbsp;<![endif]><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>IV.<span style="mso-spacerun: yes">  </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                </span>Ukupan iznos dohotka – Total
  amount of income: ………………………..………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                </span>Datum isplate<span style="mso-spacerun: yes">  </span>– Date of payment :
  ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                </span>Ukupan iznos poreza – Total
  amount of tax: ………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span></span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>PRILOŽENI DOKUMENTI (broj i naziv) –
  Documents attached (number and title):<span style="mso-spacerun: yes">
  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili
  u<span style="mso-spacerun: yes">  </span></span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>-
  In<span style="mso-spacerun: yes">  </span>the Republic of Croatia or in:
  …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Na broj računa – To the account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Kod (banka) – With the (Bank): …………………………………………………………………<span style="mso-spacerun:
  yes">
  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='fonle=' font-size:10.0pt;mso-bidi-font- 8.0pt;mso-ansi-language:en-us'><span style="mso-spacerun: yes">   </span><span style="mso-spacerun: yes">            </span>Otvorenog na ime – Opened in the
  name of: …………………………………………………….</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoBodyText3 style='tab-stops:12.6pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes"> </span><span style="mso-spacerun: yes">
  </span>II., ispunjava sljedeće uvjete – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>The
  undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>He
  is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poznato
  mi je da Porezna uprava Republike Hrvatske može poreznom tijelu u državi
  rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>podnositelja zahtjeva davati podatke o sadržaju
  ovog zahtjeva </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>– I am aware of<span style="mso-spacerun:
  yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Croatian
  Tax Administration can disclose the information given in this Application to
  the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Authorities
  in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis – Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VIII.
  POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span san style="mso-spacerun: yes">           </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis –
  Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>UPUTA ZA POPUNJAVANJE: <b>LICENCE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Ovaj obrazac podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja
porezne obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Obrazac 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, VI i
VII popunjava podnositelj zahtjeva, točke I i III popunjava isplatitelj, a
točku VIII 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Za svakog isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS
FOR FILLING IN THE FORM: </span><span style='mso-bidi-font-size:8.0pt;
mso-ansi-language:HR'>ROYALTIES<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>This
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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
The form consist of four copies. The first copy is for the claimant, the second
for the payer of the income, the third copy for the<span style="mso-spacerun:
yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Tax
Administration of the Republic of Croatia, and the forth copy for the foreign
tax authority. Items II, IV, V, VI and VII are to be filled in by the claimant,
items I and III by the payer of income, and the item VIII 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 remaining<span style="mso-spacerun:
yes">   </span>copies to the claimant (for the claimant, payer of the income,
and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span></span><span lang=EN-US style='mso-bidi-font-size:
8.0pt;font-weight:normal'>For each payer and for each payment a separate claim
is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span></span>Application for tax relief,emption 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. <o:p></o:p></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun:
yes">                 </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun: yes">      </span><span style="mso-spacerun:
yes">                        </span>- za Poreznu upravu Republike Hrvatske -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY
3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>- for the Tax Administration of the Republic of Croatia –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA
LICENCE<span style="mso-spacerun: yes">  </span>I<span style="mso-spacerun:
yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>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
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>27. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 27 of Income Tax Act
(&quot;Official Gazette&quot;, number177/04 ) and Article 31 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O STJECATELJU LICENCE –
  INFORMATION ON THE LICENSEE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Ime i prezime / naziv tvrtke – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-fonidi-font-size:8.0pt;mso-ansi-languaEN-US'>Full name / business name: ……………………………..…………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj (MBG ili matični broj) – Number (identification number / tax
  number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Zanimanje / djelatnost – Occupation: …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                        </span>Ulica i broj – Street and number:
  ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Poštanski broj – Postal code:
  ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                         </span>Država – State:
  ………………………………………………………………………………………</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – DAVATELJU LICENCE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – LICENSOR:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>– Full name / business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Pravni oblik – Legal form: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Broj – Number: ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Zanimanje / djelatnost – Occupation: …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište / sjedište – Address: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                              </span><span style="mso-spacerun:
  yes">                </span>Ulica i broj – Street and number:
  ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Poštanski broj –
  Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                                               </span>Država – State:
  ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of the
  representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Prebivalište /sjedište – Address. ………………………………………………………………………………….</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;border-bottom:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:9.75pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:115.85pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:115.85pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">  </span>PREDMET UGOVORA O LICENCI – SUBJECT MATTER
  OF LICENCE:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>3.1.&nbsp;&nbsp; Prava intelektualnog
  vlasništva – Intelectual property rights<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste prava intelektualnog vlasništva – Form of intellectual property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>…………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>…………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Registracija pravja prava intelektualnog vlasništva tration of intellectual
  property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Država registracije –
  Country of registration: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Broj registracije –
  Registration number: ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Datum registracije – Date
  of registration: ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Nositelj prava intelektualnog vlasništva prema registru – Registered owner of
  intellectual property right:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ime
  i prezime / naziv tvrtke – Full name / business name: …………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Pravni
  oblik – Legal form: ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Zanimanje
  / djelatnost – Occupation: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prebivalište
  / sjedište – Address: …………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ulica
  i broj – Street and number: …………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=DE style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:DE'>Poštanski broj – Postal
  code: ………………….<span style="mso-spacerun: yes">        </span></span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Grad – City: ……………………….…<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Država
  – State: ………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.2.</span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>&nbsp;&nbsp; <b>Prava na korištenje pokretnina</b> ( između ostalog
  leasing – ugovori) -<span style="mso-spacerun: yes">  </span>Right to use
  movable property <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>(under
  a leasing or another agreement)<span style="mso-spacerun: yes">       </span><span style="mso-spacerun: yes">                     </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.2.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste pokretnina – Type of movable property: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>………………………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.</span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>&nbsp;&nbsp; <b>Autorska prava</b> (prava koja ne spadaju pod točku
  3.1.) – Copyrights (other than those under paragraph 3.1.)<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste autorskog prava – Form of copyright: ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Naziv zaštićenog dijela – Title of protected work: ………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Autor – Author<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ime
  – Name: ……………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prezime
  – Surname: ……………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prebivalište
  / sjedište – Address: <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ulica
  i broj – Street and number: …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poštanski
  broj – Postal code: ………………………..Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Država
  – State: …………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Davatelj
  licence ovlašten je za davanje licence na temelju – The licensor is
  authorized to grant licence by virtue of:
  ……………………………………………………………………………………………. <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>&nbsp;<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>IV.<span style="mso-spacerun: yes">  </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                </span>Ukupan uznos dohotka – Total amount of income:
  ………………………..………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0ze:10.0pt;mso-bidi-font-size:
  8.-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                </span>Datum isplate<span style="mso-spacerun: yes">
  </span>– Date of payment : ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun:
  yes">                </span>Ukupan iznos poreza – Total amount of tax:
  ………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span></span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>PRILOŽENI DOKUMENTI (broj i naziv) –
  Documents attached (number and title):<span style="mso-spacerun: yes">
  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili
  u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun:
  yes">  </span>the Republic of Croatia or in: …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Na broj računa – To the
  account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (Bank): …………………………………………………………………<span style="mso-spacerun:
  yes">
  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: …………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoBodyText3 style='tab-stops:12.6pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>–
  He is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj
  – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
  mso-ansi-language:EN-US'>He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poznato
  mi je da Porezna uprava Republike Hrvatske može poreznom tijelu u državi
  rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>podnositelja
  zahtjeva davati podatke o sadržaju ovog zahtjeva – I am aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Croatian
  Tax Administration can disclose the information given in this Application to
  the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Authorities
  in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNorma style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">                   </span><span style="mso-spacerun: yes">                  </span>Potpis - Signature<o:p></o:p></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VIII.
  POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - </span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>The claimant is the
  resident <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>of …………………. Under Article ……………………….. of the Agreement for the
  avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span><span style="mso-spacerun: yes"> </span>taxation between the Republic
  of Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext .5pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:57.8pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:57.8pt'>
  <p class=MsoNormal style='margin-left:21.6pt;text-indent:-21.6pt'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes"> </span>IX.<span style="mso-spacerun: yes">    </span>NAPOMENE POREZNE
  UPRAVE REPUBLIKE HRVATSKE (ako ih ima) – CROATIAN TAX AUTHORITIES REMARKS (if
  any)<o:p></o:p></span></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>UPUTA ZA POPUNJAVANJE: <b>LICENCE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Ovaj obrazac podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja
porezne obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Obrazac 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, VI i
VII popunjava podnositelj zahtjeva, točke I i III popunjava isplatitelj, a
točku VIII 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Za svakog isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endi<![endif]><o:p></o:p></span></p>

ss=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Zahtjev 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.<o:p></o:p></span>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>INSTRUCTIONS FOR
FILLING IN THE FORM: </span><span lang=EN-US style='mso-bidi-font-size:8.0pt'>ROYALTIES<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
This 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Tax
Administration of the Republic of Croatia, and the forth copy for the foreign
tax authority. Items II, IV, V, VI and VII are to be filled in by the claimant,
items I and III by the payer of income, and the item VIII 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 remaining<span style="mso-spacerun:
yes">   </span>copies to the claimant (for the claimant, payer of the income,
and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>For each payer and for each payment a
separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>Application 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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span lang=EN-US style='font-weight:normal'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><span style="mso-spacerun: yes">                 </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span><span style="mso-spacerun:
yes">    </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H
R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za inozemno porezno
tijelo -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY
4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                         </span>- for the foreign tax
authority –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA
LICENCE<span style="mso-spacerun: yes">  </span>I<span style="mso-spacerun:
yes">  </span>SLIČNA DAVANJA PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG
OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I ………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p classp class=MsoBodyText3 align=center sext-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>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
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> 27. </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o porezu na dohodak
(&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona o porezu na dobit
(&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be given in this
application are requested under Article 27 of Income Tax Act (&quot;Official
Gazette&quot;, number 177/04 ) and Article 31 of Profit Tax Act (&quot;Official
Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O STJECATELJU LICENCE –
  INFORMATION ON THE LICENSEE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Ime i prezime / naziv tvrtke – Full
  name / business name: ……………………………..…………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………...<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Broj (MBG ili matični broj) – Number (
  identification number / tax number):… ………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Zanimanje / djelatnost – Occupation:
  …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">      </span>Prebivalište / sjedište – Address:
  ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                        </span>Ulica i broj –
  Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ……………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:124.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – DAVATELJU LICENCE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – LICENSOR:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  ……………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Zanimanje / djelatnost – Occupation:
  …………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ……………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                                                     pan>Poštanski broj – Postal code: ………………Grad – City: ……………………………..<o:p></o:p></span></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  ………………………………………………………………………………….<span style="mso-spacerun: yes">  </span><b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:9.75pt'>
  <td width=588 valign=top style='width:441.0pt;border:none;border-bottom:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:9.75pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:115.85pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:115.85pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>III.<span style="mso-spacerun: yes">  </span>PREDMET UGOVORA O LICENCI – SUBJECT MATTER
  OF LICENCE:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:18.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>3.1.&nbsp;&nbsp; Prava intelektualnog
  vlasništva – Intelectual property rights<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste prava intelektualnog vlasništva – Form of intellectual property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>…………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>…………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Registracija prava intelektualnog vlasništva – Registration of intellectual
  property right:<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Država registracije –
  Country of registration: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Broj registracije –
  Registration number: ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:54.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Datum registracije – Date
  of registration: ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoBodyText3 style='margin-left:99.0pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.1.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Nositelj prava intelektualnog vlasništva prema registru – Registered owner of
  intellectual property right:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ime
  i prezime / naziv tvrtke – Full name / business name: …………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Pravni
  oblik – Legal form: ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Zanimanje
  / djelatnost – Occupation: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prebivalište
  / sjedište – Address: …………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ulica
  i broj – Street and number: …………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=DE style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:DE'>Poštanski broj – Postal
  code: ………………….<span style="mso-spacerun: yes">        </span></span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Grad – City: ……………………….…<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Država
  – State: ………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.2.</span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>&nbsp;&nbsp; <b>Prava na korištenje pokretnina</b> ( između ostalog
  leasing – ugovori) -<span style="mso-spacerun: yes">  </span>Right to use
  movable property <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>(under
  a leasing or another agreement)<span style="mso-spacerun:
  yes">                            </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.2.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste pokretnina – Type of movable property:</span><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'> ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>………………………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>3.3.&nbsp;&nbsp; <b>Autorska prava</b> (prava koja
  ne spadaju pod točku 3.1) – </span><span lang=EN-US style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Copyrights (other than
  those under paragraph 3.1)<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Vrste autorskog prava – Form of copyright:</span><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'> ……………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>3.3.2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Naziv zaštićenog dijela – Title of </span><span lang=EN-US style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>protected work:
  ………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal stylel style='margin-left:99.0pt'><span -us style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>3.3.3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Autor – Author<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ime
  – Name: ……………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prezime
  – Surname: ……………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Prebivalište
  / sjedište – Address: <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Ulica
  i broj – Street and number: …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poštanski
  broj – Postal code: ………………………..Grad – City: ……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:99.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Država
  – State: …………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Davatelj
  licence ovlašten je za davanje licence na temelju – The licensor is
  authorized to grant licence by virtue of:
  ……………………………………………………………………………………………. <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:44.65pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:44.65pt'>
  <p class=MsoBodyText3><span lang=EN-US style='mso-bidi-font-size:8.0pt'>IV.<span style="mso-spacerun: yes">  </span>PODACI O DOHOTKU – DESCRIPTION OF THE
  INCOME:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:54.0pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                </span>Ukupan uznos dohotka – Total
  amount of income: ………………………..………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                </span>Datum isplate<span style="mso-spacerun: yes">  </span>– Date of payment :
  ……………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                </span>Ukupan iznos poreza – Total
  amount of tax: ………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">    </span></span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">   </span>PRILOŽENI DOKUMENTI (broj i naziv) –
  Documents attached (number and title):<span style="mso-spacerun: yes">
  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>………………………………………………………………………………………………………<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VI.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA –
  PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span><span style="mso-spacerun:
  yes">  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt'>U Republici Hrvatskoj ili u<span style="mso-spacerun: yes">  </span>-
  In<span style="mso-spacerun: yes">  </span>the Republic of Croatia or in:
  …………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Na broj računa – To the
  account number: ………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (Bank): …………………………………………………………………<span style="mso-spacerun:
  yes">                        </span><span style="mso-spacerun:
  yes">                                          </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: …………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoBodyText3 style='tab-stops:12.6pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt'>VII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – </span><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>The undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=Ml><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:35.25pt;text-indent:-18.0pt;mso-list:
  l1 level1 lfo12;tab-stops:list 35.25pt'><![if !supportLists]><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>1.<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  </span></span><![endif]><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – He is the beneficial owner of
  the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:35.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:35.25pt;text-indent:-18.0pt;mso-list:
  l1 level1 lfo12;tab-stops:list 35.25pt'><![if !supportLists]><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>2.<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  </span></span><![endif]><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:35.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>kroz
  djelatnost registriranu u Republici Hrvatskoj – He did not derive income, as
  defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:35.25pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Poznato mi je da Porezna uprava Republike Hrvatske može poreznom
  tijelu u državi rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>podnositelja zahtjeva davati podatke o sadržaju ovog zahtjeva – I am
  aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Croatian Tax Administration can disclose the information given in this
  Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>Authorities in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>VIII.
  POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">         </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal anter style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>UPUTA ZA POPUNJAVANJE: <b>LICENCE<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Ovaj obrazac podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja
porezne obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza na 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Obrazac 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, VI i
VII popunjava podnositelj zahtjeva, točke I i III popunjava isplatitelj, a
točku VIII 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Za svakog isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>INSTRUCTIONS FOR
FILLING IN THE FORM: </span><span lang=EN-US style='mso-bidi-font-size:8.0pt'>ROYALTIES<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
This 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
The 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<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>Tax Administration
of the Republic of Croatia, and the forth copy for the foreign tax authority.
Items II, IV, V, VI and VII are to be filled in by the claimant, items I and
III by the payer of income, and the item VIII 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 remaining<span style="mso-spacerun: yes">   </span>copies
to the claimant (for the claimant, payer of the income, and the Tax
Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>For<span style="mso-spacerun: yes">
</span>each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span lang=EN-US style='mso-bidi-font-size:8.0pt;font-weight:normal'>4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span style="mso-spacerun: yes">  </span>Application 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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><span style="mso-spacerun: yes">                 </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![esp;<![endif]><o:p></o:p></span></p>class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">     </span></span><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span><b>R
E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun:
yes">                                          </span>- za podnositelja
zahtjeva -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span><span style="mso-spacerun: yes">          </span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>COPY
1<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                                </span>- for the claimant
–<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE POREZNE
OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA NAKNADE ZA
DJELATNOST OBAVLJENU U REPUBLICI HRVATSKOJ,<span style="mso-spacerun: yes">
</span>PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE
HRVATSKE I ………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX
RELIEF, TAX EXEMPTION OR TAX REFUND FOR<span style="mso-spacerun: yes">
</span>INDEPENDENT PERSONAL SERVICES RENDERED IN THE REPUBLIC OF CROATIA UNDER
THE AGREEMENT FOR THE AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF
CROATIA AND ……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>48. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 48 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04 ) and Article 31 <span style="mso-spacerun: yes"> </span>of Profit Tax Act (&quot;Official
Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU – INFORMATION ON
  THE PAYER:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke – Full
  name / business name: ……………………………..………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Pravni oblik – Legal form:
  ……………………………………………………………………………………….……………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Broj (MBG ili mG ili matični broj) – Number
  ( ication number / tax number):… …………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                        </span>Ulica i broj –
  Street and number: …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:124.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU NAKNADE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECEPIENT OF THE
  REMUNERATION:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>(umjetničko ime, ako ga ima –
  artistic name, if there is any): …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form: ……………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  …………………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span><span style="mso-spacerun:
  yes">       </span>Ime i prezime / naziv zastupnika (ako ga ima) – Name of
  the representative (if any): ………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  …………………………………………………………………………………. …………… <b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal style='margin-left:5.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<b>III. VRSTA DJELATNOSTI (umjetničke,
  književne i druge djelatnosti) – TYPE OF ACTIVITY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>( for example artistic, literary
  and other activities):<span style="mso-spacerun: yes">  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span lang=EN-GB style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>IV. TRAJANJE DJELATNOSTI ( priredba/e je/su
  održana/e u razdoblju) – THE DURATION OF THE <o:p></o:p></span></h2>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>ACTIVITY ( the perfomance/s was/were
  held during the period):<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Početak – Beginning:
  ……………………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Završetak – End:
  ………………………………………………………………………………………………. …………………<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span lang=EN-GB style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">  </span>PODACI O
  NAKNADI – INFORMATION ABOUT THE REMUNERATION:<o:p></o:p></span></h2>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>a) ukupna naknada – total amount of
  the remuneration: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>b) postotak porezno priznatih
  troškova – the percentage of the deductible costs: ………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>c) (a)-(b)= porezna osnovica –
  (a)-(b)=tax base: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>d) iznos poreza – the amount of tax:
  …………………………………………………………………………………………………………………<o:p></o:p></span> <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>e) datum uplate – date of payment:
  …………………………………………………………………………… ………………….<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span>VI.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">                                                     </span>………………………………………………………………………………………………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">   </span>VII.<span style="mso-spacerun: yes">
  </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili
  u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun:
  yes">  </span>the Republic of Croatia or in: ………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>Na broj računa – To the account
  number: ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (bank): ……………………………………………………………………………………………..<span style="mso-spacerun:
  yes">                                     </span><span style="mso-spacerun:
  yes">                             </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: ………………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>VIII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">       </span></span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Potpisnik jamči da su gore navedeni podaci istiniti te da podnositelj
  zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>II., ispunjava sljedeće uvjete – The undersigned certifies that the
  beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – He is the beneficial owner of
  the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>kroz
  djelatnost registriranu u Republici Hrvatskoj – He did not derive income, as
  defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poznato
  mi je da Porezna uprava Republike Hrvatske može poreznom tijelu u državi
  rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>podnositelja
  zahtjeva davati podatke o sadržaju ovog zahtjeva – I am aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Croatian
  Tax Administration can disclose the information given in this Application to
  the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>authorities
  in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">        </span></b></span>IX.<span style="mso-spaceruns">   </span>POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>OSTALI
DOHODAK<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza za naknadu za obavljenu djelatnost
osobi koja ima prebivalište, uobičajno boravište ili sjedište (rezidentu) u
državi s kojom je Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog
oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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,<span style="mso-spacerun: yes">
</span>III, IV and 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>OTHER INCOME<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>This form is
submitted for tax relief, tax exemption or tax refund for iremuneration to a
resident of the country with which the Republic of Croatia entered into
Agreement for the Avoidance of double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>The form consist
of four copies. The first copy is for the claimant, the second for thefor the payer of
the income, the tpy for the<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>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<span style="mso-spacerun: yes">  </span>the
claimant, items I, III, IV and V by the payer of 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 remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for the claimant,
payer of the income, and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun: yes"> </span>For<span style="mso-spacerun: yes">
</span>each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun: yes"> </span>Application 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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'>&nbsp;<span style="mso-spacerun: yes">         </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span><span style='mso-tab-count:2'>                          </span></b>PRIMJERAK
2<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt'><span style="mso-spacerun: yes">
</span><span style='mso-tab-count:2'>                         </span><span style="mso-spacerun: yes">   </span><span style="mso-spacerun:
yes">       </span>- za isplatitelja dohotka -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span><span style='mso-tab-count:2'>                          </span><span style="mso-spacerun: yes">     </span></span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'>COPY 2<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
yes">                                                     </span><span style="mso-spacerun: yes">                  </span>- for the payer of the
income –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE
POREZNE OBVEZE, IZUZIMANJE OD POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA NAKNADE
ZA <u>DJELATNOST </u>OBAVLJENU U REPUBLICI HRVATSKOJ,<span style="mso-spacerun:
yes">  </span>PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU
REPUBLIKE HRVATSKE I ………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-bidi-font-size:8.0pt;mso-ansi-language:HR'>APPLICATION FOR TAX
RELIEF, TAX EXEMPTION OR TAX REFUND FOR<span style="mso-spacerun: yes">
</span>INDEPENDENT <u>PERSONAL SERVICES</u> RENDERED IN THE REPUBLIC OF CROATIA
UNDER THE AGREEMENT FOR THE AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC
OF CROATIA AND ……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='fon10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>48. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 48 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04) and Article 31 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU – INFORMATION ON
  THE PAYER:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke – Full
  name / business name: ……………………………..………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Pravni oblik – Legal form:
  ……………………………………………………………………………………….……………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Broj (MBG ili matični broj) – Number
  ( identification number / tax number):… …………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                        </span>Ulica i broj –
  Street and number: …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:124.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU NAKNADE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECEPIENT OF THE
  REMUNERATION:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>(umjetničko ime, ako ga ima –
  artistic name, if there is any): …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ……………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  …………………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                           </span><span style="mso-spacerun: yes">                    </span>Država – State:
  ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  …………………………………………………………………………………. …………… <b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441dth:441.0pt;border:solid windowtext
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal style='margin-left:5.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:8.0pt'>&nbsp;<b>III. VRSTA DJELATNOSTI (umjetničke,
  književne i druge djelatnosti) – TYPE OF ACTIVITY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>( for example artistic, literary
  and other activities):<span style="mso-spacerun: yes">  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:HR'>&nbsp;</span><span lang=EN-GB style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>IV. TRAJANJE DJELATNOSTI ( priredba/e je/su
  održana/e u razdoblju) – THE DURATION OF THE <o:p></o:p></span></h2>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>ACTIVITY ( the perfomance/s was/were
  held during the period):<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>Početak – Beginning:
  ……………………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">        </span>Završetak – End:
  ………………………………………………………………………………………………. …………………<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:HR'>&nbsp;</span><span lang=EN-GB style='font-size:
  10.0pt;mso-bidi-font-size:8.0pt'>V.<span style="mso-spacerun: yes">
  </span>PODACI O NAKNADI – INFORMATION ABOUT THE REMUNERATION:<o:p></o:p></span></h2>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>a) ukupna naknada – total amount of
  the remuneration: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>b) postotak porezno priznatih
  troškova – the percentage of the deductible costs: ………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>c) (a)-(b)= porezna osnovica –
  (a)-(b)=tax base: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>d) iznos poreza – the amount of tax:
  ………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">       </span>e) datum uplate – date of payment:
  …………………………………………………………………………… ………………….<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">  </span>VI.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">                                                     </span>………………………………………………………………………………………………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">   </span>VII.<span style="mso-spacerun: yes">
  </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>U Republici Hrvatskoj ili
  u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun:
  yes">  </span>the Republic of Croatia or in: ………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>Na broj računa – To the account
  number: ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the (bank):
  ……………………………………………………………………………………………..<span style="mso-spacerun:
  yes">
  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: ………………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">     </span>VIII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;</span></b><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">       </span></span></b><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
  EN-US'>Potpisnik jamči da su gore navedeni podaci istiniti te da podnositelj
  zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:
  8.0pt;mso-ansi-language:EN-US'><span style="mso-spacerun: yes">
  </span>II., ispunjava sljedeće uvjete – The undersigned certifies that the
  beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span lang=EN-US style='font-size:10.0pt;mso-pt;mso-bidi-font-size:
  8.0pt;msoanguage:EN-US'><span style="mso-spacerun: yes">
  </span>under II fulfills the following conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stvarni je korisnik gore navedenog dohotka – He is the beneficial owner of
  the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Dohodak u smislu navedenog Ugovora o izbjegavanju dvostrukog oporezivanja
  nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>kroz
  djelatnost registriranu u Republici Hrvatskoj – He did not derive income, as
  defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>the
  mentioned Agreement for the avoidance of double taxation, through the
  activity registered in the Republic of Croatia, <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Poznato
  mi je da Porezna uprava Republike Hrvatske može poreznom tijelu u državi
  rezidentnosti<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>podnositelja
  zahtjeva davati podatke o sadržaju ovog zahtjeva – I am aware of<span style="mso-spacerun: yes">  </span>the fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>Croatian
  Tax Administration can disclose the information given in this Application to
  the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:18.0pt'><span lang=EN-US style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:EN-US'>authorities
  in the country of residence of the claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<b><span style="mso-spacerun: yes">        </span>IX.<span style="mso-spacerun: yes">
  </span>POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između Republike
  Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">         </span><span style="mso-spacerun:
  yes">  </span>…………………………………..<span style="mso-spacerun: yes">
  </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>OSTALI
DOHODAK<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza za naknadu za obavljenu djelatnost
osobi koja ima prebivalište, uobičajno boravište ili sjedište (rezidentu) u
državi s kojom je Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog
oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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 i VIII
popunjava podnositelj zahtočke I,<span style="mso-spacerun: yes">
</span>III, IV and 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:18.0pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>OTHER INCOME<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>This form is
submitted for tax relief, tax exemption or tax refund for iremuneration to a
resident of the country with which the Republic of Croatia entered into
Agreement for the Avoidance of double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>The form consist
of four copies. The first copy is for the claimant, the second for the payer of
the income, the third copy for the<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>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<span style="mso-spacerun: yes">
</span>the claimant, items I, III, IV and V by the payer of 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
remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for
the claimant, payer of the income, and the Tax Administration of the Republic
of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.0pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun: yes"> </span>For<span style="mso-spacerun: yes">
</span>each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:35.25pt;text-align:justify;text-indent:
-18.0pt;mso-list:l32 level1 lfo34;tab-stops:list 35.25pt'><![if !supportLists]><span style='mso-ansi-language:HR;font-weight:normal'>4.<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><![endif]><span style='mso-ansi-language:HR;font-weight:normal'>Application
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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-sifont-size:12.0pt'><span style="msoun: yes">               </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
12.0pt'><span style="mso-spacerun:
yes">                                          </span>- za Poreznu upravu
Republike Hrvatske -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>COPY
3<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'><span style="mso-spacerun:
yes">                              </span>- for the Tax Administration of the
Republic of Croatia<span style="mso-spacerun: yes">  </span>–<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD
POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA NAKNADE ZA DJELATNOST OBAVLJENU U
REPUBLICI HRVATSKOJ,<span style="mso-spacerun: yes">  </span>PREMA UGOVORU O
IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-ansi-language:HR'>APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX
REFUND FOR<span style="mso-spacerun: yes">  </span>INDEPENDENT PERSONAL
SERVICES RENDERED IN THE REPUBLIC OF CROATIA UNDER THE AGREEMENT FOR THE
AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span style='font-size:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>48. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 48 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04) and Article 31 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU – INFORMATION ON
  THE PAYER:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke – Full
  name / business name: ……………………………..………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Pravni oblik – Legal form:
  ……………………………………………………………………………………….……………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Broj (MBG ili matični broj) – Number
  ( identification number / tax number):… …………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">               </span><span style="mso-spacerun:
  yes">         </span>Ulica i broj – Street and number:
  …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:124.5pt'>
  <p class=MsoNormal><spmal><span style='font-size:10.0pt;m-font-size:12.0pt'>&nbsp;<b>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU NAKNADE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></b></span></spmal></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>CLAIMANT – RECEPIENT OF THE
  REMUNERATION:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:12.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">   </span><span style="mso-spacerun:
  yes">     </span>(umjetničko ime, ako ga ima – artistic name, if there is
  any): …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ……………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  …………………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  …………………………………………………………………………………. …………… <b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal style='margin-left:5.25pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>III. VRSTA DJELATNOSTI (umjetničke, književne i
  druge djelatnosti) – TYPE OF ACTIVITY <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>( for example artistic, literary
  and other activities):<span style="mso-spacerun: yes">  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span style='font-size:10.0pt;mso-bidi-font-size:
  14.0pt;mso-ansi-language:HR'>&nbsp;</span><span lang=EN-GB style='font-size:
  10.0pt;mso-bidi-font-size:14.0pt'>IV. TRAJANJE DJELATNOSTI ( priredba/e je/su
  održana/e u razdoblju) – THE DURATION OF THE <o:p></o:p></span></h2>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>ACTIVITY ( the perfomance/s was/were
  held during the period):<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:12.0pt'>Početak – Beginning:
  ……………………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Završetak – End:
  ………………………………………………………………………………………………. …………………<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span lang=EN-GB style='font-size:10.0pt;
  mso-bidi-font-size:14.0pt'>V.<span style="mso-spacerun: yes">  </span>PODACI
  O NAKNADI – INFORMATION ABOUT THE REMUNERATION:<o:p></o:p></span></h2>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>a) ukupna naknada – total amount of
  the remuneration: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>b) postotak porezno priznatih troškova
  – the percentage of the deductible costs: ………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>c) (a)-(b)= porezna osnovica –
  (a)-(b)=tax base: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>d) iznos poreza – the amount of tax:
  ………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>e) datum uplate – date of payment:
  …………………………………………………………………………… ………………….<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">  </span>VI.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun:
  yes">                                                     </span>………………………………………………………………………………………………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;pa.0pt;padding:0cm 5.4pt 0cm 5.4pt;
t:25.5pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes"> </span><span style="mso-spacerun: yes">
  </span>VII.<span style="mso-spacerun: yes">   </span>NAČIN POVRATA VIŠE
  PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">             </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>U Republici Hrvatskoj ili
  u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun:
  yes">  </span>the Republic of Croatia or in: ………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">             </span>Na broj računa – To the account
  number: ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (bank): ……………………………………………………………………………………………..<span style="mso-spacerun:
  yes">
  </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: ………………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<b><span style="mso-spacerun: yes">     </span>VIII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:12.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – The
  undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>under II fulfills the following
  conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>1.</span><span style='font-size:10.0pt;mso-bidi-font-size:
  7.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>Stvarni je korisnik gore
  navedenog dohotka – He is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>2.</span><span style='font-size:10.0pt;mso-bidi-font-size:
  7.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>Dohodak u smislu navedenog
  Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj
  – He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>the mentioned Agreement for the avoidance of
  double taxation, throught the activity registered in the Republic of Croatia,
  <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>Poznato mi je da Porezna uprava Republike Hrvatske
  može poreznom tijelu u državi rezidentnosti<span style="mso-spacerun: yes">
  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>podnositelja zahtjeva davati podatke o sadržaju
  ovog zahtjeva – I am aware of<span style="mso-spacerun: yes">  </span>the
  fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>Croatian Tax Administration can disclose the
  information given in this Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>authorities in the country of residence of the
  claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">             </span>………………………………………<span style="mso-spacerun: yes">                     </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<b><span style="mso-spacerun: yes">      </span><span style="mso-spacerun:
  yes">  </span>IX.<span style="mso-spacerun: yes">   </span>POTVRDA POREZNOG
  TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">
  </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacso-spacerun: yes">           <o:p></o:p></span></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:57.8pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:57.8pt'>
  <p class=MsoNormal style='margin-left:21.6pt;text-indent:-21.6pt'><b><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt'><span style="mso-spacerun:
  yes">      </span>X. NAPOMENE POREZNE UPRAVE REPUBLIKE HRVATSKE (ako ih ima)
  – CROATIAN TAX AUTHORITIES REMARKS (if any)<o:p></o:p></span></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>OSTALI
DOHODAK<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza za naknadu za obavljenu djelatnost
osobi koja ima prebivalište, uobičajno boravište ili sjedište (rezidentu) u
državi s kojom je Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog
oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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,<span style="mso-spacerun: yes">
</span>III, IV and 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:17.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>OTHER INCOME<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>This form is
submitted for tax relief, tax exemption or tax refund for iremuneration to a
resident of the country with which the Republic of Croatia entered into
Agreement for the Avoidance of double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>The form consist
of four copies. The first copy is for the claimant, the second for the payer of
the income, the third copy for the<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>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<span style="mso-spacerun: yes">
</span>the claimant, items I, III, IV and V by the payer of 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 remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for the claimant,
payer of the income, and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:jusign:justify'><span style='mso-ansige:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun: yes"> </span>For<span style="mso-spacerun: yes">
</span>each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:18.7pt;text-align:justify;text-indent:
-1.45pt;mso-list:l6 level1 lfo37;tab-stops:list 18.7pt'><![if !supportLists]><span style='mso-ansi-language:HR;font-weight:normal'>4.<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><![endif]><span style='mso-ansi-language:HR;font-weight:normal'>Application
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. <o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='text-align:justify'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;</span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun:
yes">  </span><span style="mso-spacerun: yes">   </span><o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span><b>R E P U B L I K A<span style="mso-spacerun: yes">   </span>H R V A T S K A<span style="mso-spacerun:
yes">
</span></b>PRIMJERAK 4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>MINISTARSTVO
FINANCIJA-POREZNA UPRAVA</span></b><span style='font-size:10.0pt;mso-bidi-font-size:
12.0pt'><span style="mso-spacerun:
yes">                                                  </span>- za inozemno
porezno tijelo -<o:p></o:p></span></p>

<p class=MsoNormal style='tab-stops:216.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
</span>THE REPUBLIC OF CROATIA<span style="mso-spacerun:
yes">
</span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>COPY
4<o:p></o:p></span></p>

<p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>MINISTRY
OF FINANCE-TAX ADMINISTRATION</span></b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'><span style="mso-spacerun:
yes">                                                </span>- for the foreign
tax authority –<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText2 align=center style='text-align:center'><b><span style='mso-ansi-language:HR'>ZAHTJEV ZA UMANJENJE POREZNE OBVEZE, IZUZIMANJE OD
POREZA ILI POVRAT VIŠE PLAĆENOG POREZA NA NAKNADE ZA DJELATNOST OBAVLJENU U
REPUBLICI HRVATSKOJ,<span style="mso-spacerun: yes">  </span>PREMA UGOVORU O
IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU REPUBLIKE HRVATSKE I
………………………………………<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>('Narodne novine –
Međunarodni ugovori', broj: …………………)<o:p></o:p></span></b></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>

<p class=MsoBodyText3 align=center style='text-align:center'><span style='mso-ansi-language:HR'>APPLICATION FOR TAX RELIEF, TAX EXEMPTION OR TAX
REFUND FOR<span style="mso-spacerun: yes">  </span>INDEPENDENT PERSONAL
SERVICES RENDERED IN THE REPUBLIC OF CROATIA UNDER THE AGREEMENT FOR THE
AVOIDANCE OF DOUBLE TAXATION BETWEEN THE REPUBLIC OF CROATIA AND
……………………………………………<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>('Official Gazette –
International Agreements', number: …………………………………)<o:p></o:p></span></b></p>

<h1><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;
font-weight:normal'>Podaci</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;mso-ansi-language:HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>iz</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:
HR;font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>ovog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>Zahtjeva</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>potrebni</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>su</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>zbog</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> </span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>primjene</span><span style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:normal'> č</span><span lang=EN-GB style='font-size:10.0pt;
mso-bidi-font-size:8.0pt;font-weight:normal'>lanka</span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;mso-ansi-language:HR;
font-weight:neight:normal'> </span><span style='ze:10.0pt;mso-bidi-font-size:
8.0pt;mso-ansi-language:HR;font-weight:normal'>48. </span><span lang=EN-GB style='font-size:10.0pt;mso-bidi-font-size:8.0pt;font-weight:normal'>Zakona o
porezu na dohodak (&quot;Narodne novine&quot;, broj 177/04) i članka 31. Zakona
o porezu na dobit (&quot;Narodne novine&quot;, broj 177/04) – <i>The data to be
given in this application are requested under Article 48 of Income Tax Act
(&quot;Official Gazette&quot;, number 177/04) and Article 31 of Profit Tax Act
(&quot;Official Gazette&quot;, number 177/04)<o:p></o:p></i></span></h1>

<table border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;
 border-collapse:collapse;border:none;mso-border-alt:solid windowtext 1.0pt;
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt'>
 <tr style='height:96.0pt'>
  <td width=589 valign=top style='width:441.75pt;border:solid windowtext 1.0pt;
  padding:0cm 5.4pt 0cm 5.4pt;height:96.0pt'>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>I.<span style="mso-spacerun: yes">   </span>PODACI O ISPLATITELJU – INFORMATION ON
  THE PAYER:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Ime i prezime / naziv tvrtke – Full
  name / business name: ……………………………..………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Pravni oblik – Legal form:
  ……………………………………………………………………………………….……………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Broj (MBG ili matični broj) – Number
  ( identification number / tax number):… …………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">                        </span>Ulica i broj –
  Street and number: …………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">                         </span>Poštanski broj –
  Postal code: ………………………………Grad – City: ………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">                         </span>Država – State:
  ……………………………………………………………………………………………………… <o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:124.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:124.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<b>II.<span style="mso-spacerun: yes">   </span>PODACI<span style="mso-spacerun: yes">
  </span>O PODNOSITELJU ZAHTJEVA – PRIMATELJU NAKNADE – INFORMATION ON THE<span style="mso-spacerun: yes">                          </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">  </span><span style="mso-spacerun:
  yes">     </span>CLAIMANT – RECEPIENT OF THE REMUNERATION:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:12.0pt'>Ime i prezime / naziv tvrtke – Full name /
  business name: ……………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>(umjetničko ime, ako ga ima –
  artistic name, if there is any): …………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Pravni oblik – Legal form:
  ……………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Broj – Number:
  …………………………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Prebivalište / sjedište – Address:
  ……………………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
  </span>Ulica i broj – Street and number: ………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
  </span>Poštanski broj – Postal code: ………………Grad – City: ……………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">
  </span>Država – State: ………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>Ime i prezime / naziv zastupnika
  (ako ga ima) – Name of the representative (if any): ………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>Prebivalište /sjedište – Address.
  …………………………………………………………………………………. …………… <b><o:p></o:p></b></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal style='margin-left:5.25pt'><b><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>III. VRSTA DJELATNOSTI (umjetničke, književne i
  druge djelatnosti) – TYPE OF ACTIVITY <o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>( for example artistic, literary
  and other activities):<span style="mso-spacerun: yes">  </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span style='font-size:10.0pt;mso-bidi-font-size:
  14.0pt;mso-ansi-language:HR'>&nbsp;</span><span lang=EN-GB style='font-size:
  10.0pt;mso-bidi-font-size:14.0pt'>IV. TRAJANJE DJELATNOSTI ( priredba/e je/su
  održana/e u razdoblju) – THE DURATION OF THE <o:p></o:p></span></h2>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>ACTIVITY ( the perfomance/s was/were
  held during the period):<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style=style='font-size:10.0pt;mso-bidi-fe:12.0pt'><span style="mso-spacerun: yes">        </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:12.0pt'>Početak – Beginning:
  ……………………………………………………………………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">        </span>Završetak – End:
  ………………………………………………………………………………………………. …………………<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <h2 style='margin-left:4.5pt'><span style='font-size:10.0pt;mso-bidi-font-size:
  14.0pt;mso-ansi-language:HR'>&nbsp;</span><span lang=EN-GB style='font-size:
  10.0pt;mso-bidi-font-size:14.0pt'>V.<span style="mso-spacerun: yes">
  </span>PODACI O NAKNADI – INFORMATION ABOUT THE REMUNERATION:<o:p></o:p></span></h2>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>a) ukupna naknada – total amount of
  the remuneration: ………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>b) postotak porezno priznatih
  troškova – the percentage of the deductible costs: ………………………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>c) (a)-(b)= porezna osnovica – (a)-(b)=tax
  base: ………………………………………………………………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>d) iznos poreza – the amount of tax:
  ………………………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>e) datum uplate – date of payment:
  …………………………………………………………………………… ………………….<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<b><span style="mso-spacerun: yes">  </span>VI.<span style="mso-spacerun: yes">
  </span>PRILOŽENI DOKUMENTI (broj i naziv) – Documents attached (number and
  title): </b><span style="mso-spacerun:
  yes">                                                     </span>………………………………………………………………………………………………………………………………………….<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<b><span style="mso-spacerun: yes">   </span>VII.<span style="mso-spacerun: yes">
  </span>NAČIN POVRATA VIŠE PLAĆENOG POREZA – PROCEDURE OF THE REFUND: <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">             </span></span></b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>U Republici Hrvatskoj ili
  u<span style="mso-spacerun: yes">  </span>- In<span style="mso-spacerun:
  yes">  </span>the Republic of Croatia or in: ………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">             </span>Na broj računa – To the account
  number: ……………………………………………………………………………………<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">               </span>Kod (banka) – With the
  (bank): ……………………………………………………………………………………………..<span style="mso-spacerun:
  yes">                 </span><span style="mso-spacerun:
  yes">                                                 </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">               </span>Otvorenog na ime – Opened in
  the name of: ………………………………………………………………………………..<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<b><span style="mso-spacerun: yes">     </span>VIII.<span style="mso-spacerun: yes">
  </span>IZJAVA PODNOSITELJA ZAHTJEVA – STATEMENT OF THE CLAIMANT:<o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span></span></b><span style='font-size:
  10.0pt;mso-bidi-font-size:12.0pt'>Potpisnik jamči da su gore navedeni podaci
  istiniti te da podnositelj zahtjeva, naveden pod točkom<span style="mso-spacerun: yes">    </span><o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>II., ispunjava sljedeće uvjete – The
  undersigned certifies that the beneficial owner mentioned <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">       </span>under II fulfills the following
  conditions:<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>1.</span><span style='font-size:10.0pt;mso-bidi-font-size:
  7.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>Stvarni je korisnik gore
  navedenog dohotka – He is the beneficial owner of the mentioned <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>income,<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>2.</span><span style='font-size:10.0pt;mso-bidi-font-size:
  7.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>Dohodak u smislu navedenog
  Ugovora o izbjegavanju dvostrukog oporezivanja nije ostvaren <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>kroz djelatnost registriranu u Republici Hrvatskoj
  – He did not derive income, as defined in<o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>the mentioned Agreement for the avoidance of
  double taxation, throught the activity registered in the Republic of Croatia,
  <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>Poznato mi je da Porezna uprava Republike Hrvatske
  može poreznom tijelu u državi rezidentnosti<span style="mso-spacerun: yes">
  </span><o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-sifont-size:10.0pt;
  mso-bidi-font-.0pt'>podnositelja zahtjeva davati podatke o sadržaju
  ovog zahtjeva – I am aware of<span style="mso-spacerun: yes">  </span>the
  fact that the <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>Croatian Tax Administration can disclose the
  information given in this Application to the tax <o:p></o:p></span></p>
  <p class=MsoNormal style='margin-left:17.25pt'><span style='font-size:10.0pt;
  mso-bidi-font-size:12.0pt'>authorities in the country of residence of the
  claimant.<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">             </span>……………………………………… <span style="mso-spacerun: yes">                    </span>…………………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">                 </span>Mjesto i datum – Place and
  date<span style="mso-spacerun: yes">
  </span>Potpis - Signature<o:p></o:p></span></p>
  </td>
 </tr>
 <tr style='height:25.5pt'>
  <td width=588 valign=top style='width:441.0pt;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext 1.0pt;padding:0cm 5.4pt 0cm 5.4pt;
  height:25.5pt'>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<b><span style="mso-spacerun: yes">        </span>IX.<span style="mso-spacerun:
  yes">   </span>POTVRDA POREZNOG TIJELA DRŽAVE REZIDENTNOSTI PODNOSITELJA<span style="mso-spacerun: yes">     </span><o:p></o:p></b></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span><b>ZAHTJEVA – CERTIFICATE OF TAX
  AUTHORITY OF CLAIMANT'S COUNTRY <o:p></o:p></b></span></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">          </span>OF RESIDENCE:<o:p></o:p></span></b></p>
  <p class=MsoNormal><b><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></b></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>Podnositelj zahtjeva je rezident
  ………………… prema članku …………….. Ugovora o izbjegavanju<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>dvostrukog oporezivanja između
  Republike Hrvatske i …………………… - The claimant is the resident <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>of …………………. Under Article
  ……………………….. of the Agreement for the avoidance of double <o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>taxation between the Republic of
  Croatia and ………………………….<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">           </span>…………………………<span style="mso-spacerun: yes">           </span>…………………………………..<span style="mso-spacerun: yes">            </span>……………………………..<o:p></o:p></span></p>
  <p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><span style="mso-spacerun: yes">     </span>Mjesto i datum – Place and date<b><span style="mso-spacerun: yes">                  </span></b>Pečat – Stamp<span style="mso-spacerun: yes">                                     </span>Potpis
  - Signature<o:p></o:p></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoNormal align=center style='text-align:center'><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'>UPUTA ZA POPUNJAVANJE: <b>OSTALI
DOHODAK<o:p></o:p></b></span></p>

<p class=MsoNormal style='text-align:justify'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt'>&nbsp;<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Ovaj obrazac
podnosi<span style="mso-spacerun: yes">  </span>se radi umanjenja porezne
obveze, izuzimanja od poreza ili povrata više plaćenog<span style="mso-spacerun: yes">  </span>poreza za naknadu za obavljenu djelatnost
osobi koja ima prebivalište, uobičajno boravište ili sjedište (rezidentu) u
državi s kojom je Republika Hrvatska sklopila Ugovor o izbjegavanju dvostrukog
oporezivanja.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Obrazac 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,<span style="mso-spacerun: yes">
</span>III, IV and 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).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Za svakog
isplatitelja i za svaku isplatu podnosi se poseban zahtjev.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>Zahtjev 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.<o:p></o:p></span></p>

<p class=MsoBodyTele='margin-left:38.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 align=center style='margin-left:17.25pt;text-align:center'><span style='mso-ansi-language:HR;font-weight:normal'>INSTRUCTIONS FOR FILLING IN THE
FORM: </span><span style='mso-ansi-language:HR'>OTHER INCOME<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt'><span style='mso-ansi-language:
HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>1.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>This form is
submitted for tax relief, tax exemption or tax refund for iremuneration to a
resident of the country with which the Republic of Croatia entered into
Agreement for the Avoidance of double Taxation.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>2.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'>The form consist
of four copies. The first copy is for the claimant, the second for the payer of
the income, the third copy for the<span style="mso-spacerun: yes">  </span><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>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<span style="mso-spacerun: yes">
</span>the claimant, items I, III, IV and V by the payer of 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 remaining<span style="mso-spacerun: yes">   </span>copies to the claimant (for the claimant,
payer of the income, and the Tax Administration of the Republic of Croatia).<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:2.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>3.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun: yes"> </span>For<span style="mso-spacerun: yes">
</span>each payer and for each payment a separate claim is made.<o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:20.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></p>

<p class=MsoBodyText3 style='margin-left:17.25pt;text-align:justify'><span style='mso-ansi-language:HR;font-weight:normal'>4.</span><span style='mso-bidi-font-size:7.0pt;mso-ansi-language:HR;font-weight:normal'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style='mso-ansi-language:HR;font-weight:normal'><span style="mso-spacerun: yes"> </span>Application 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.
&nbsp;<span style="mso-spacerun: yes">              </span><o:p></o:p></span></p>

<p class=MsoNormal><![if !supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></p>

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                                <span>Pravilnik, NN 1/2005-1 </span>
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                                        <td><span class='key'>Dio NN:</span> Službeni</td>
                                    </tr>

                                    <tr>
                                        <td><span class='key'>Vrsta dokumenta:</span> Pravilnik</td>
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                                        <td><span class='key'>Izdanje:</span>
                                            NN 1/2005&nbsp;&nbsp;&nbsp;<div class="edition-icon"></div>

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                                        <td><span class='key'>Broj dokumenta u izdanju:</span> 1</td>
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                                        <td><span class="key">Donositelj:</span>Ministarstvo financija</td>
                                    </tr>

                                    <tr>
                                        <td><span class='key'>Datum tiskanog izdanja:</span> 3.1.2005.</td>
                                    </tr>

                                    <tr>
                                        <td><span class='key'>ELI:</span> <a href="https://narodne-novine.nn.hr/eli/sluzbeni/2005/1/1">/eli/sluzbeni/2005/1/1</a></td>
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