Form 04/ĐTV-TNCN - Personal Income Tax Declaration (Circular No. 80/2021/TT-BTC dated September 29, 2021 by the Ministry of Finance)
SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom - Happiness
PERSONAL INCOME TAX DECLARATION
(For individuals receiving dividends in the form of securities, interest recorded as capital increase, securities awarded to existing shareholders upon transfer, and for organizations or individuals declaring taxes on behalf of individuals)
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[01a] Date of occurrence: … day … month … year ...
[01b] Month … year ... / Quarter … year ...
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[02] First time: [03] Additional submission: …
Individual entitled to tax exemption/reduction under the Double Taxation Avoidance Agreement (*)
Organization declaring tax on behalf of multiple individuals
[[04] Name of taxpayer: …………………………………………
[06] Address: ……………………………………
[07] District: … [08] City/Province: …
[09] Phone: … [10] Fax:** … [11] Email:** …
[12] Name of organization or individual declaring on behalf (if any): …
[14] Address: …
[15] District: … [16] City/Province:** …
[17] Phone: … [18] Fax:** … [19] Email:** …
[20] Tax agent (if any): …
[22] Tax agent contract: No: ... Date: ...
Currency unit: Vietnamese Dong
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No. |
Issuer Organization |
Securities Code |
Quantity of Securities |
Nominal Value of Securities |
Total Dividend Value (or Interest) |
Total Value as Book Value (or Market Value) |
Tax Payable |
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I |
Securities Paid as Dividends |
[23] |
[24] |
[25] |
[26] |
[27] |
[28] |
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1 |
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2 |
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… |
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II |
Securities Awarded to Existing Shareholders |
[34] |
[35] |
[36] |
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1 |
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2 |
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… |
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III |
Interest Recorded as Capital Increase |
[37] |
[38] |
[39] |
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1 |
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2 |
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… |
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Total:
[40] [41] [42]
I affirm that the information declared is correct and I am legally responsible for the declared details.
NHTAX AGENT EMPLOYEE
Name: …
Professional certificate number: ...
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…, Date … Month … Year …
TAXPAYER or LEGAL REPRESENTATIVE OF THE TAXPAYER or ORGANIZATION, INDIVIDUAL DECLARING ON BEHALF
(Signature, full name, title, and stamp (if any) / Electronic signature)
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Notes:
(*) In cases where the individual is entitled to tax exemption/reduction under the Double Taxation Avoidance Agreement, they must submit the tax declaration of the first tax declaration along with the notification of tax exemption/reduction according to the Agreement as regulated.