FEDERALNO MINISTARSTVO FINANSIJAPorezna uprava Federacije BiHFEDERAL MINISTRY OF FINANCETax Administration of FBiH___________________________________Ispostava Porezne uprave - Branch Office of TA

od - from: do - to:

I PODACI O REZIDENTU/ ISPLATIOCU - DATA ON RESIDENT/ PAYER

1. Naziv firme - Name of Company:

2. Identifikacioni broj - TIN:

3. Šifra i naziv osnovne djelatnosti - Code and title of principal activity:

4. Adresa sjedišta (uprave) - Headquarters (Management) Address:Mjesto - Place: Država - State:

PRIJAVA/POTVRDA O OBRAČUNATOM I PLAĆENOM POREZU PO ODBITKU I/ILI PRIMJENI UGOVORAO IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA

Obrazac - Form P-OD

DECLARATION/CERTIFICATE ON CALCULATED AND PAID WITHHOLDING TAX AND/OR APPLICATIONOF AGREEMENT ON AVOIDING DOUBLE TAXATION

za period - for the period

II PODACI O NEREZIDENTU/ PRIMAOCU - DATA ON NON-RESIDENT/ RECIPIENT

1. Naziv firme - Name of Company:

2. Identifikacioni broj - TIN:

3. Adresa sjedišta (uprave) - Headquarters (Management) Address:

Mjesto - Place: Država - State:

III

#

PODACI O OSTVARENOM PRIHODU I OBRAČUNATOM POREZU PO ODBITKU - DATA ON GENERATED INCOME AND CALCULATED WITHHOLDING TAX

41 2

Broj ugovora / fakture - Contract No. / Invoice No.

Vrsta prihoda (opis) - Revenue Type (description)

5

Bruto prihod u KM - Gross

Income (KM)

Stopa poreza - Tax Rate

Iznos poreza - Tax Amount

3

IV

#

V

1.2.3.4.

5.6.7.

VI NAPOMENA POREZNE UPRAVE (ako je ima) - TAX ADMINISTRATION REMARKS (if any)

PODACI O OBRAČUNATOM POREZU PREMA UGOVORU O IZBJEGAVANJU DVOSTRUKOG OPOREZIVANJA - DATA ON CALCULATED TAX PER AGREEMENT ON AVOIDING DOUBLE TAXATION

PRILOŽENI DOKUMENTI (naziv i broj) - SUPPORTING DOCUMENTATION (title and number) - enclosed

Tax AmountBroj ugovora /

fakture - Contract No. / Invoice No.

Vrsta prihoda (opis) - Revenue Type (description)

10

Stopa poreza iz Ugovora -

Agreement Tax Rate

Bruto prihod u KM - Gross

Income (KM)

6 7 8 9

INSTRUCTION

1. Form P-OD is filed as declaration/certificate on paid withholding tax and/or application of the agreement on avoiding double taxation of legalentities whose headquarters offices are outside BiH. 2. Form is to be filled out in 4 copies where one remains with payer, one is provided to the recipient of the income, one to the Tax Administration andone to the foreign tax body. 3. Item I, II, III and IV shall be filled out by the payer, and V and VI by the Tax Administration.

UPUTSTVO ZA POPUNJAVANJE

1.Obrazac P-OD podnosi se u svrhu prijave/potvrde o plaćenom porezu po odbitku i/ili primjene ugovora o izbjegavanju dvostrukog oporezivanjapravnih lica čije je sjedište van teritorije Bosne i Hercegovine. 2.Obrazac se popunjava u četiri primjerka od kojih jedan ostaje kod isplatioca, jedan primaocu prihoda, jedan Poreznoj upravi i jedan inostranomporeznom organu. 3. Tačku I, II, III i IV popunjava isplatilac, a V i VI popunjava Porezna uprava.

Datum - Date:

Obračun sačinio - Calculated by M.P. - STAMP Odgovorno lice - Liable Person

INSTRUCTION

1. Form P-OD is filed as declaration/certificate on paid withholding tax and/or application of the agreement on avoiding double taxation of legalentities whose headquarters offices are outside BiH. 2. Form is to be filled out in 4 copies where one remains with payer, one is provided to the recipient of the income, one to the Tax Administration andone to the foreign tax body. 3. Item I, II, III and IV shall be filled out by the payer, and V and VI by the Tax Administration.

UPUTSTVO ZA POPUNJAVANJE

1.Obrazac P-OD podnosi se u svrhu prijave/potvrde o plaćenom porezu po odbitku i/ili primjene ugovora o izbjegavanju dvostrukog oporezivanjapravnih lica čije je sjedište van teritorije Bosne i Hercegovine. 2.Obrazac se popunjava u četiri primjerka od kojih jedan ostaje kod isplatioca, jedan primaocu prihoda, jedan Poreznoj upravi i jedan inostranomporeznom organu. 3. Tačku I, II, III i IV popunjava isplatilac, a V i VI popunjava Porezna uprava.

INSTRUCTION

1. Form P-OD is filed as declaration/certificate on paid withholding tax and/or application of the agreement on avoiding double taxation of legalentities whose headquarters offices are outside BiH. 2. Form is to be filled out in 4 copies where one remains with payer, one is provided to the recipient of the income, one to the Tax Administration andone to the foreign tax body. 3. Item I, II, III and IV shall be filled out by the payer, and V and VI by the Tax Administration.

UPUTSTVO ZA POPUNJAVANJE

1.Obrazac P-OD podnosi se u svrhu prijave/potvrde o plaćenom porezu po odbitku i/ili primjene ugovora o izbjegavanju dvostrukog oporezivanjapravnih lica čije je sjedište van teritorije Bosne i Hercegovine. 2.Obrazac se popunjava u četiri primjerka od kojih jedan ostaje kod isplatioca, jedan primaocu prihoda, jedan Poreznoj upravi i jedan inostranomporeznom organu. 3. Tačku I, II, III i IV popunjava isplatilac, a V i VI popunjava Porezna uprava.