ATTACHMENT A3 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, or will be 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, or will be enforceable, under the laws of The Netherlands;(d)A Request for Assistance in Collection will be made by The Netherlands for the recovery of the tax claim pursuant to the Convention and under section 263-15 of the Taxation Administration Act 1953 by (date).(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 the conserving of assets for the purposes of such collection; and(3)advise that (please advise of the stage in the process of assessment or recovery that the Revenue Claim has reached under the laws and administrative practices of the Netherlands); and(4)advise that (please advise how and in what respects conservancy relates to assets, including ‘claims and expectancies’, of ^name of debtor^ against whom the Revenue Claim applies or relates to a third party against whom process is available as a consequence of the tax claim, pursuant to which the third party may be obliged to disgorge property or otherwise contribute to the funds or property of ^name of debtor^).

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.