FORM FOR A REQUEST FOR ASSISTANCE IN COLLECTION OR CONSERVANCY – THIS MUST BE COMPLETED IN ITS ENTIRETY
ATTACHMENTA2FORM FOR A REQUEST FOR ASSISTANCE IN COLLECTION OR CONSERVANCY – THIS MUST BE COMPLETED IN ITS ENTIRETYA Request for Assistance in Collection and Conservancy
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^; |
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. |