[별지 제3호 서식]

Date, signature and stamp of the office

RESIDENT CERTIFICATE
For the Purpose of Double Taxation Convention between Kingdom of Belgium and the Republic of Korea
Ⅰ. Korean Payer of Income
Address
Name
Ⅱ. Beneficial Owner of Income
Address
Name
Ⅲ. Description of Income
Nature of Income	Date of Payment		Accrual Period of Income	Amount of Income
Interest
Dividends
Royalties
The undersigned Belgian tax office certifies that the beneficial owner of income is a resident of Belgium.