总机构所在地 Place of head office _____________________________________
2、 在取得（或将取得）下列所得： Has derived or will derive the following income in ____________________________________________________
所得项目
Items of income
支付人名称
Payer’s name
支付金额
Amount of payment
支付日期
Date of payment
3、根据中华人民共和国同 国签订的避免双重征税协定第 条的规定，是中国居民。 is a Chinese resident, according to the provisions of Article _____________ in the Avoidance of Double Taxation Agreement Between the People’s Republic of China and ______________ .
