Modle n AAC310F-12I

Direction rgionale ou (inter) prfectorale de:

.
Subdivision de :..............................................

Destin l'administration fiscale

trangre
For use by the foreign tax authority

ATTESTATION DE RESIDENCE FISCALE

Certificate of Residence
Demande dapplication de la convention fiscale entre le Maroc et
Application for implementation of the tax treaty between Morocco and

..
Dclaration du bnficiaire des revenus (Information on the beneficiary)
A servir par le bnficiaire ( to be completed by the beneficiary)

Nom et prnom/Raison Sociale:.............................................................................................................................................................

Name and surname/Business name

Adresse :......................................................................................................................................................................................................
Address

Numro didentification fiscale : ....

Tax identification number

Nature des revenus (types of income) (*) :

Dividendes (Dividends)
Intrts (Interest)
Redevances (Royalties)
Revenus demploi (Employment income)
Pensions (Pensions)

Priv (Private)
Public (Public)

Publiques (from government service)

Autres que publiques (other than from government service)

Bnfices d'entreprises (Income from business activity)

Autres revenus (dcrire la nature du revenu) .................................................................................................................................
Other income (describe the nature of the income)

A...le...
Place

date

Signature et cachet du bnficiaire

Signature and stamp of the beneficiary

Dclaration de l'administration fiscale (Declaration of the tax authority)

Le Chef de la subdivision de la fiscalit des personnes morales/personnes physiques atteste que le bnficiaire est
rsident au Maroc au sens de la convention fiscale susvise au titre de l'anne (ou des annes)
.............................................................., et quil est assujetti limpt sur les socits
ou limpt sur le revenu
.
The head of the subdivision of legal persons or individuals certifies that the beneficiary is a resident of Morocco for the purpose of the
abovementioned tax treaty, in the year(s) ... and is subject to
corporation tax
or income tax
.

Ale...
Place

date

(*) Mettre une croix dans la case approprie (Check the appropriate box).

Signature et cachet de ladministration

Signature and official stamp