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Business Case

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_____________________

Application form
_____________________

Application for tax exemption under section 13(12) of Income Tax Act on foreign-sourced dividend to be remitted to Singapore from 22 Jan 2009 to 21 Jan 2010

Inland Revenue Authority of Singapore
(Tax Policy & Ruling Branch)
55 Newton Road
Singapore 307987

[pic]

INSTRUCTIONS

1. To assist us in evaluating your application expeditiously, please provide the information requested as completely as possible. If space is insufficient, a separate sheet may be used.

2. All information given will be held in the strictest confidence. Where information is not yet available or inapplicable, please indicate accordingly.

3. It may take you 10 minutes to fill up this form.

4. This application should be sent to: The Comptroller of Income Tax Inland Revenue Authority of Singapore Tax Policy & Ruling Branch 55 Newton Road Singapore 307987.

1. Particulars of Applicant:

|Name | |
|Address | |
|Income Tax Reference No. | |
|Nature of business/activity | |
|Telephone No. | |

2. Name and Address of contact person:

|Name | |
|Designation | |
|Address | |
|Email Address for correspondence | |
|Telephone No. | |

3. Particulars of holding/ultimate holding company of the Applicant (if applicable):

|Name | |
|Address | |
|Income Tax Reference No. | |
|Nature of business/activity | |

4. Particulars of foreign-sourced dividend to be received in Singapore

|a |Name of foreign company paying dividend to applicant | |
|b |Address of foreign company | |
|c |Country in which the foreign company is a tax resident| |
|d |Nature of business/activities of the foreign company | |
|e |Percentage of shareholding held by the applicant in | |
| |the foreign company as at 21 Jan 2009 | |
|f |Total amount of dividend paid by foreign company and | |
| |date of payment | |
|g |Amount of foreign dividend to be received by applicant| |
| |in Singapore and expected date of receipt | |
|h |Expected use of the remitted foreign dividend | |

5. Checklist of documents to be submitted

|a |Document(s) to show that the applicant was a shareholder of the foreign company before |Yes / No |
| |22 Jan 2009 | |
|b |Copy of the foreign company’s statement of accounts for the year ended _______________ |Yes / No |
|c |Document(s) to show the amount of dividend paid by the foreign company |Yes / No |
|d |Document(s) to show the amount of foreign dividends to be received by the applicant in |Yes / No |
| |Singapore | |

6. Declaration

I declare that the particulars stated above and the accompanying information are true and correct to the best of my/our knowledge.

____________________________ _________________ Authorised signature of applicant Date

____________________________

Full name and designation

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