FORMULARIO N 1492 (FORM N 1492) CERTIFICADO DE RENTAS Y RETENCIONES (REVENUES AND RETENTIONS CERTIFICATE) Base Legal: Artculo 13 del

TUO de la ley del Impuesto a la Renta aprobado por el Decreto Supremo N 179-2004-EF y modificatorias. (Legal framework : Article 13 of revenue taxes law of Ordered Only Text (TUO), approved by executive order N 179-2004-EF and modifications). 1. DATOS DEL AGENTE DE RETENCIN (RETENTION AGENT INFORMATION) Apellidos y Nombres, denominacin o razn social (Surnames and names, designation or social reason) Rgistro nico de Contribuyente - RUC (Payer unique logging) Domicilio Fiscal (Legal residence) Representante legal - acreditado en el RUC (Legal agent - established in the RUC) Apellidos y nombres (Surnames and names) Documento de Identidad (Identify document) ( ) DNI Nmero (Number) 2. DATOS DEL EXTRANJERO (FOREIGNER INFORMATION) Apellidos y Nombres (Surnames and names) Documento de Identidad (Identify document) ( ) Pasaporte (Passport) Nmero (Number) Condicin Migratoria: (Migratory condition) ( ) Religioso (Religious) ( ) Independiente (Independent ( ) Estudiante (Student) ( ) Inmigrante Migrant ( ) Trabajador (Worker) ( ) Otros - especificar (Others - specify) ( ) Carnet de Extranjera (Foreigner identication card) Nacionalidad (Nationality) ( ) Otros - especificar (Others - specify) ( ) Pasaporte (Passport) ( ) Carnet de Extranjera (Foreigner identication card) ( ) Otros - especificar (Others - specify)

3. DETALLE DE LAS RENTAS DE FUENTE PERUANA GENERADAS DURANTE SU PERMANENCIA EN EL PAS Y DE LAS RETENCIONES EFECTUADAS (DETAILS OF PERUVIAN SOURCE REVENUES MAKED DURING THEIR STAY IN THE COUNTRY AND DETAILS FROM MAKED RETENTIONS) Concepto -ver tabla 1 (Item - see table ) Detalle de literal c - ver tabla 2 (Details from lettering (c) - See table 2) Importe de las rentas pagadas, acreditadas o puestas a disposicin (Amount of paying revenues, established or putted in arrangement) Importe de la retencin (Amount or retention) Literal (Lettering) Literal (Lettering) S/. S/.

DETALLE DE DIVIDENDOS Y OTRAS FORMAS DE DISTRIBUCIN DE UTILIDADES (Details of dividends and other forms of utilities distribution) Importe de los dividendos y otras formas de distribucin de utilidades (Amount of dividens and other forms of utilities distribution) S/.

Importe de hola que retencin tal (Amount of retention) S/. como te va lo dispuesto en los incisos (b) y (c) del artculo 13 del TUO de la Ley del Impuesto a la Renta, se emite el presente certificado donde consta que se han efectuado las retenciones En cumplimiento de
correspondientes (In agreement with the regulations of clauses (b) and (c) from artcule 13 of revenue taxes law of TUO, is expressed this certificate where is signed that the corresponding retentions have been done.)

Fecha de Emisin (Issuance date) Fecha de vigencia (Efective until)

Firma del agente de retencin o representante legal Sello de recepcin acreditado en el RUC. (Reception stamp) (Retention agent signature of Legal Agent established in (Uso exclusivo de autoridades migratorias the RUC) (For use of migratory autorities only) El certificado tendr vigencia por 30 das calendarios contados a partir de la fecha de su emisin (The certificate will have effective by 30 days counted since the issuance date)

INSTRUCTIONS

1. RETENTION AGENT INFORMATION in This part, we must to assing the identification and the legal residence of the retention agent that is giving the certificate.

2. FOREIGNER INFORMATION in This part, its important to show the identification information of the foreigner citizen, the condition of migration tha they could have used to enter to the country, their nationality and the arrival and departure dates from the country.

3. DETAILS OF PERUVIAN SOURCE REVENUES MAKED DURING THEIR STAY IN THE COUNTRY AND DETAILS FROM DONE RETENTIONS item: To assign the lettering in agreement to Table 1

TABLE 1
a) First category revenue: Revenues produced by leasign, sub leasing and goods assingnment. b) Second category revenue without considering the mentioned cases in lettering (g) c) Revenues corresponding to the concepts of the article 48 of revenue taxes law of TUO. d) Third revenue category without considering the mentioned cases in lettering (g): Revenues from comerce, industry and another considered in law.

hola que tal e) Fourth category revenues: Revenues from independent jobs. como te va

f) Fith category revenues: Revenues from jobs with relation of dependence. g) Revenues in according to amount as a result of deduce the principal amount return, considering revenues that are not included in letterings from a) to f), proceeding of conveyance goods and rights or explotation of goods with depreciation. Legal framework:Article 76 of revenue taxes law of TUO, approved by executive orden N 179-2004-EF and modifications

Lettering c) details:In case to assing lettering c) of table 1 in the title item, you must mark the associated lettering of table 2

TABLE 2
a) Insurances activities b) Ship rent. c) Air transport rent. d) Air transport between the Republic and foreign e) Shipping between the Republic and foreign, or afreightment f) Telecomunications service between the Republic and foreing g) News international agencies h) Movies distribution and their similarities for their use by natural people and legal entities i) To provide containeirs for transport inside or since the country to the foreing (No includes transport) j)Demurrage of containers for transport k)Assigment of rights of sing television retransmition Legal framework:Article 48 of revenue taxes law of TUO, approved by executive orden N 179-2004-EF and modifications