PDF《股息所得税退还申请表》

DYNAM JAPAN HOLDINGS 股份有限公司 式1(Form 1) 股息所得税退还申请表 APPLICATION FORM FOR TAX REFUND 1.

退款金接收人详情 Details of recipient of refunds 姓名或名称 Full name 个人 Individual 住所或居所 Domicile or residence 电话号码: Telephone Number: 电邮地址: E-mail address: 国籍 Nationality 法团或其他实 体Corporation or other entity 总办事处或主要办事处 所在地 Place of head office or main office 电话号码: Telephone Number: 电邮地址: E-mail address: 2. 股份数目/证券公司或金融机关名 Number of shares/Financial Institutions or Securities Companies 股份数目 Number of shares (DYNAM JAPAN : 06889) 填写委托"DYNAM JAPAN"股票的证券公司或金融机关名称 Fill name as financial institutions or the securities companies, as the "DYNAM JAPAN" shares depositary destination. (The such as banks and securities firms.) 3. 收取退款方式选择 Options for receiving your refund (1) 可以选择日本银行帐号(含:日本邮政局开设的普通储备账户)和日本境外银行帐号,股息所得税的退款金以日圆付款, 必要时,本公司会按照指定的汇 率兑换成港币汇到下面填写的银行帐号内. You may opt to provide either a Japanese bank account (including an account of Japan Post Bank) or a bank account outside Japan. Refunds of withholding taxes will be paid on Japanese yen and if applicable, converted into the HKD currencies of your bank account at an exchange rate specified by company. (2) 仅於相应地方填妥资料 Only enter your information in the corresponding fields. 退款汇入: Receipt by transfer to: 银行 Bank name 分行 Branch name 账户类别及账号编码 Type of account, and account number 账户持有人名称 Name of account holder 日本银行账号 A Japanese bank account 日本境外银行账号 A bank account outside Japan 分行地址(国家、城市): Branch address (Country, City, etc.): 4.代理人详情 If this form is prepared and submitted by an Agent, fill out the following columns. 代理人名 Agent name 电话号码 Telephone number 地址(居所或住所) Agent location (Domicile or residence)