## Objava Priloga uz Pravilnik o porezu na dobit

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

30

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

## PRILOG

### OBRAZAC-LICENCE OBRAZAC-KAMATE UZ PRAVILNIK O POREZU NA DOBIT

Uz Pravilnik o porezu na dobit objav­ljuje se obrazac-licence primjerak
1 do 4 i Upute za popu­njava­nje: Licence, te obrazac-kamate primjerak 1 do 4 i
Upute za popu­njava­nje: Kamate.

Urbroj: 50501-01-8
Zagreb, 4. siječ­nja 2001.

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

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OBRAZAC-LICENCE
FORM - ROYALTIES

PRIMJERAK
1

-
za podnositelja zahtjeva-

*COPY 1*

*- for the claimant -*

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

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

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

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

        Zanimanje / djelatnost – *Occupation:*

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.3.3. Autor - *Author*

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

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

                Prebivalište / sjedište – *Address:*

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

#

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PRIMJERAK
2

-
za isplatitelja dohotka -

COPY
2

-
for the payer of the income -

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

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

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

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

**if !supportEmptyParas endif**

if !supportEmptyParas endif

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

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

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

        Zanimanje / djelatnost – *Occupation:*

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.3.3. Autor - *Author*

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

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

                Prebivalište / sjedište – *Address:*

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

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

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

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

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

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if !supportEmptyParas endif

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

PRIMJERAK
3

-
za Poreznu upravu Republike Hrvatske -

COPY
3

-
for the Tax Administration of the Republic of Croatia -

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

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

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

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

**if !supportEmptyParas endif**

if !supportEmptyParas endif

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

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

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

        Zanimanje / djelatnost – *Occupation:*

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.3.3. Autor - *Author*

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

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

                Prebivalište / sjedište – *Address:*

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

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

# if !supportEmptyParas endif

# if !supportEmptyParas endif

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

# if !supportEmptyParas endif

PRIMJERAK
4

-
za inozemno porezno tijelo -

COPY
4

-
for the foreign tax authotity -

if !supportEmptyParas endif

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

**if !supportEmptyParas endif**

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

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

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

**if !supportEmptyParas endif**

if !supportEmptyParas endif

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

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

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

        Zanimanje / djelatnost – *Occupation:*

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.3.3. Autor - *Author*

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

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

                Prebivalište / sjedište – *Address:*

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

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

# if !supportEmptyParas endif

if !supportEmptyParas endif

*if !supportEmptyParas endif*

*UPUTA ZA POPUNJAVANJE: **LICENCE***

***if !supportEmptyParas endif***

***if !supportEmptyParas endif***

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

if !supportEmptyParas endif

if !supportLists2.      endifObrazac
se sastoji od četiri primjerka. Prvi je primjerak za podnositelja zahtjeva,
drugi za isplatitelja, treći za Poreznu upravu Ministarstva financija Republike
Hrvatske, a četvrti za inozemno porezno tijelo. Točke II, 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).

if !supportEmptyParas endif

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

if !supportEmptyParas endif

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

if !supportEmptyParas endif

*if !supportEmptyParas endif*

*if !supportEmptyParas endif*

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

***if !supportEmptyParas endif***

***if !supportEmptyParas endif***

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

if !supportEmptyParas endif

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

if !supportEmptyParas endif

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

if !supportEmptyParas endif

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

if !supportEmptyParas endif

if !supportEmptyParas endif

OBRAZAC–
KAMATE
FORM – INTEREST

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

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

**if !supportEmptyParas endif**

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

NA KAMATE, PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene  članka 26. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 26 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

Temelj isplate – *Payment
basis:*
............................................................................................................................................................

        Datum izdavanja ili sklapanja ugovora – *Date of issue or conclusion of the contract:
......*....................................................................

        Ukupan iznos kamate – *Total amount of interest:*
..................................................................................................................................

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

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

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

**if !supportEmptyParas endif**

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

NA KAMATE, PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene  članka 26. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 26 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

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

Temelj isplate – *Payment
basis:*
............................................................................................................................................................

        Datum izdavanja ili sklapanja ugovora – *Date of issue or conclusion of the contract:
......*....................................................................

        Ukupan iznos kamate – *Total amount of interest:*
..................................................................................................................................

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

**if !supportEmptyParas endif**

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

NA KAMATE, PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene  članka 26. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 26 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

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

Temelj isplate – *Payment
basis:*
............................................................................................................................................................

        Datum izdavanja ili sklapanja ugovora – *Date of issue or conclusion of the contract:
......*....................................................................

        Ukupan iznos kamate – *Total amount of interest:*
..................................................................................................................................

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

V**III. NAPOMENE POREZNE UPRAVE
REPUBLIKE HRVATSKE (ako ih ima)- CROATIAN TAX AUTHORITIES REMARKS (if any)**

**if !supportEmptyParas endif**

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

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

# if !supportEmptyParas endif

# R E P U B L I K A  H R V A T S K A

## MINISTARSTVO FINANCIJA – POREZNA UPRAVA

***THE REPUBLIC OF CROATIA***

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

**if !supportEmptyParas endif**

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

NA KAMATE, PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA IZMEĐU

REPUBLIKE HRVATSKE I ………………………………

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

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

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

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

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

if !supportEmptyParas endif

# Podaci iz ovog Zahtjeva potrebni su zbog primjene  članka 26. Zakona o porezu na dohodak ("Narodne novine", broj 127/00.) i članka 22. Zakona o porezu na dobit ("Narodne novine", broj 127/00.) – *The data to be given in this application are requested under Article 26 of Income Tax Act ("Official Gazette", number 127/00) and Article 22 of Profit Tax Act ("Official Gazette", number 127/00)*

**if !supportEmptyParas endif**

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

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

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

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

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

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

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

Temelj isplate – *Payment
basis:*
............................................................................................................................................................

        Datum izdavanja ili sklapanja ugovora – *Date of issue or conclusion of the contract:
......*....................................................................

        Ukupan iznos kamate – *Total amount of interest:* ..................................................................................................................................

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

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

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

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

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

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

if !supportEmptyParas endif

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

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

**if !supportEmptyParas endif**

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

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

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

if !supportEmptyParas endif

if !supportEmptyParas endif

*UPUTA ZA POPUNJAVANJE: **KAMATE***

***if !supportEmptyParas endif***

if !supportLists5.      endifOvaj obrazac podnosi se radi umanjenja
porezne obveze, izuzimanja od poreza ili povrata više plaćenog 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.

if !supportEmptyParas endif

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

if !supportEmptyParas endif

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

if !supportEmptyParas endif

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

if !supportEmptyParas endif

*if !supportEmptyParas endif*

*if !supportEmptyParas endif*

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

***if !supportEmptyParas endif***

1. 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.

if !supportEmptyParas endif

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

if !supportEmptyParas endif

if !supportEmptyParas endif

3. For each payer and for each payment a separate
   claim is made.

if !supportEmptyParas endif

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

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

if !supportEmptyParas endif

Ostalo, NN 1/2001-30
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