ATTACHMENT A1 FORM FOR A REQUEST FOR ASSISTANCE IN COLLECTION OR...

I, ^name of competent authority^ of The Netherlands, one of whose addresses is ^address^:

(1)declare that:(a)I am a duly appointed competent authority of The Netherlands, for the purposes of the Multilateral Convention on Mutual Administrative Assistance in Tax Matters as amended by the 2010 Protocol (“the Convention”);(b)an amount totalling $Aust^amount^ (€^amount^) (“the Revenue Claim”) calculated as at the date of this request, is owed by ^name of debtor^ under the laws of The Netherlands, in respect of taxes and associated amounts, particulars of which are as follows:

Taxes	$Aust^amount^
Interest	$Aust^amount^
Administrative penalties	$Aust^amount^
Costs
Total	$Aust^amount^;

(c)the Revenue Claim owed by ^name of debtor^ is enforceable under the laws of The Netherlands;(d)^name of debtor^ cannot under the laws of The Netherlands prevent the collection of the Revenue Claim; and(e)the Revenue Claim is consistent with the provisions of the Convention and fulfils the requirements of the Convention; and(2)request that the Revenue Claim specified in the above declaration be accepted for collection by Australia.

Dated:

.....

^name of competent authority^

Competent authority

The Netherlands

Please return this form to the Competent Authority of the Australian Taxation Office in paper form, by electronic transmission or by facsimile.