[별지 제2호 서식]

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