Forma/ Form 4-DTA-13

Anexa nr.4
la Hotrrea Guvernului
nr. 101 din 5 februarie
Annex no. 4
to Governments Decision
no. 101 of dated February 5, 2013

_________________ nr./ no. _______________

La nr. _________________________________
of no.
CERTIFICAT / CERTIFICATE
privind atestarea impozitului pe venit achitat n Republica Moldova de ctre persoanele
fizice - ceteni strini sau apatrizi care au obinut statut de rezident al Republicii Moldova
attesting the income tax paid in the Republic of Moldova by individuals foreign citizens or stateless persons who have obtained
residence status of the Republic of Moldova.
Autoritatea competent certific n perioada anului ______________________________________________,
The competent authority certifies that in the period of the year _________________________________________________
Persoan fizic - cetean strin sau apatrid ___________________________________________________________,
The individual foreign citizen or stateless person
(numele i prenumele beneficiarului venitului / name and surname of the beneficiary of income)
Nr. paaportului______________, data eliberrii _______________, termenul de valabilitate________________________
Passport number
date of issue
term of validity
Nr. permisului de edere n Republica Moldova ____________data eliberrii___________, cod fiscal_________________
The residence permit in the Republic of Moldova no.

date of issue

tax code

A declarat venit _______________________________________________________________________________ lei,

has declared income
(suma se indic n cifre i litere / the amount is indicated in figures and words)
sau n valut strin ___________________________________________________________________________________
or in foreign currency

(suma se indic n cifre i litere / the amount is indicated in figures and words)

inclusiv din sursele de venit din Republica Moldova ___________________________________________________ lei,

including sources of income from the Republic of Moldova (suma se indic n cifre i litere / the amount is indicated in figures and words)
sau n valut strin ___________________________________________________________________________________
or in foreign currency

(suma se indic n cifre i litere / the amount is indicated in figures and words )

A achitat impozit _____________________________________________________________________________ lei.

and has paid tax

(suma se indic n cifre i litere / the amount is indicated in figures and words)

sau n valut strin _____________________________________________________________________________

or in foreign currency

Locul/Place _______________________
Data/Date _________________________

(suma se indic n cifre i litere / the amount is indicated in figures and words)

Numele i prenumele ________________________

Surname and first name
Semntura/Signature ________________________
Funcia/Position ____________________________
tampila/Stamp