【별지 제3호 서식】

RESIDENT CERTIFICATE

For the Purpose of Double Taxation Convention between

Kingdom of Belgium and the Republic of Korea

Ⅰ. Korean Payer of Income

Address
Name

Ⅱ. Beneficial Owner of Income

Address
Name

Ⅲ. Description of Income

Nature of Income	Date of Payment	Accrual Period of Income	Amount of Income
Interest
Dividends
Royalties

The undersigned Belgian tax office certifies that the beneficial owner of income is a resident of Belgium.

Date, signature and stamp of the office