[별지 제2호 서식] (2009.9.1. 개정)

Application for the certification of residence for the purpose of double taxation convention between the Netherlands and the Republic of Korea

Ⅰ. The recipient of income

①Address or / of Registered office
②Name of Company		③Name

Ⅱ. Description of the income

①Nature of income	②Due date or date of payment	③Name of the payer	④Principals or invest- ments	⑤Accrual period of income	⑥Gross amount of the income	⑦Amount of tax exemption
Interest, profit-sharing bonds
Dividends
Royalties

Ⅲ. Certificate of Residence

The undersigned certifies that the recipient of the interest / dividends / royalties concerned is a resident of the Netherlands within the meaning of Article 4 of the Convention between the Netherlands and the Republic of Korea for the avoidance of double taxation.

Date, signature and stamp

Head of the Taxation Unit at