Forma/ Form 4-DTA-13 Anexa nr.4 la Hotrrea Guvernului nr. 101 din 5 februarie Annex no. 4 to Governments Decision no. 101 of dated February 5, 2013

_________________ nr./ no. _______________La nr. _________________________________of no. CERTIFICAT / CERTIFICATEprivind atestarea impozitului pe venit achitat n Republica Moldova de ctre persoanelefizice - ceteni strini sau apatrizi care au obinut statut de rezident al Republicii Moldova attesting the income tax paid in the Republic of Moldova by individuals foreign citizens or stateless persons who have obtained residence status of the Republic of Moldova.

Autoritatea competent certific n perioada anului ______________________________________________, The competent authority certifies that in the period of the year _________________________________________________

Persoan fizic - cetean strin sau apatrid ___________________________________________________________,

The individual foreign citizen or stateless person (numele i prenumele beneficiarului venitului / name and surname of the beneficiary of income)

Nr. paaportului______________, data eliberrii _______________, termenul de valabilitate________________________

Passport number date of issue term of validity

Nr. permisului de edere n Republica Moldova ____________data eliberrii___________, cod fiscal_________________

The residence permit in the Republic of Moldova no.date of issuetax code

A declarat venit _______________________________________________________________________________ lei,

has declared income(suma se indic n cifre i litere / the amount is indicated in figures and words)

sau n valut strin ___________________________________________________________________________________

or in foreign currency(suma se indic n cifre i litere / the amount is indicated in figures and words)

inclusiv din sursele de venit din Republica Moldova ___________________________________________________ lei,

including sources of income from the Republic of Moldova (suma se indic n cifre i litere / the amount is indicated in figures and words)

sau n valut strin ___________________________________________________________________________________

or in foreign currency(suma se indic n cifre i litere / the amount is indicated in figures and words )

A achitat impozit _____________________________________________________________________________ lei.

and has paid tax(suma se indic n cifre i litere / the amount is indicated in figures and words)

sau n valut strin _____________________________________________________________________________

or in foreign currency (suma se indic n cifre i litere / the amount is indicated in figures and words)

Locul/Place _______________________ Data/Date _________________________Numele i prenumele ________________________ Surname and first name Semntura/Signature ________________________ Funcia/Position ____________________________ tampila/Stamp