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Nr.

i data nregistrrii la autoritatea fiscal*


Number and date of registration at the tax authority*
/.
*Numr de nregistrare ca operator de date cu caracter personal: 759
Registration number as personal data operator: 759

Chestionar pentru stabilirea rezidenei fiscale a persoanei fizice la plecarea din Romnia
Set of questions for determining the fiscal residence of the individual when leaving Romania
A. Date de identificare ale persoanei fizice rezidente/ nerezidente care pleac din Romnia
Identification data of the resident/non-resident individual leaving Romania
Nume i prenume ............................................................., Cetenie/Naionalitate ..................................,
Name and surname
Citizenship/Nationality
Cod Numeric Personal/NIF .......................................................................................................................,
Personal/Tax identification number
Data naterii (zz.ll.aaaa) ..........................................................., Anul fiscal .............................................
Date of birth (dd/mm/yyyy)
Fiscal year
Stare civil:
Civil status

cstorit()
married

necstorit()
single

divorat()
divorced

vduv()
widower/widow

B. Adresa n/n afara Romniei i perioada de edere n afara Romniei


Address in/ outside Romania and period of staying outside Romania
Adresa din Romnia (nainte de a prsi Romnia)
Address in Romania (before leaving Romania)

adresa de domiciliu ................................................................................................................................


home address
.....................................................................................................................................................................
adresa locuinei permanente ..................................................................................................................
permanent home address
.....................................................................................................................................................................
Statul n care vei locui/se solicita rezidena ..............................................................................................
Country you will live in/for which residence is requested
Adresa, telefonul i adresa de e-mail din strintate ..................................................................................
Address, phone and e-mail address from abroad
.....................................................................................................................................................................
Data plecrii din Romnia (zz.ll.aaaa) .......................................................................................................
Date of departure from Romania (dd/mm/yyyy)
Ct timp preconizai c vei petrece n afara Romniei? ............................................................................
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How long do you intend to stay outside Romania?


C. Declaraie privind rezidena fiscal
Declaration on fiscal residence
a) Suntei rezident fiscal n Romnia la data plecrii din Romnia?
Are you a fiscal resident of Romania when leaving Romania?

DA
YES

NU
NO

b) Suntei rezident fiscal ntr-un stat cu care Romnia are ncheiat


o convenie de evitare a dublei impuneri?
Are you a fiscal resident of a country that has a convention for
the avoidance of double taxation concluded with Romania?

DA
YES

NU
NO

n caz afirmativ, avei obligaie fiscal integral n acel stat?


If yes, do you have a full tax liability in that country?

DA
YES

NU
NO

c) Suntei rezident fiscal ntr-un stat cu care Romnia nu are ncheiat


o convenie de evitare a dublei impuneri?
Are you a fiscal resident of a country not having a convention for
the avoidance of double taxation concluded with Romania?

DA
YES

NU
NO

Pentru aplicarea prevederilor conveniei de evitare a dublei impuneri persoana fizic romn are
obligaia s prezinte certificatul de reziden fiscal emis de autoritatea competent a statului strin
care l consider rezident fiscal i cu care Romnia are ncheiat convenie.
For the application of the provisions of the convention for the avoidance of double taxation, the
Romanian individual is required to submit the certificate of fiscal residence issued by the competent
authority of the foreign country that considers him/her to be its fiscal resident and that has a
convention concluded with Romania.
D. Motivul plecrii din Romnia
Reason for leaving Romania
Suntei detaat n strintate de un angajator romn;
You have been detached abroad by a Romanian employer
Suntei angajat n strintate de un angajator strin;
You have been hired abroad by a foreign employer
Desfurai activitate independent n strintate;
You are performing a self-employment activity abroad
Suntei pensionar;
You are retired
Studiai, predai sau efectuai cercetare ntr-o instituie de nvmnt strin sau ntr-un institut
strin de cercetare (menionai numele i adresa instituiei)
You are studying, teaching or doing research in a foreign educational institution or research
institute (please mention the name and address of the institution)
........;
altele (explicaii) ...
others (please explain)
.
.

E. Relaia de angajare
Employment relationship
Dac vei fi angajat sau vei desfura activitate n strintate, bifai csua care vi se aplic:
If you are going to be hired or performing activity abroad, please tick the appropriate box

Suntei sau vei fi detaat n strintate de un angajator romn (menionai numele i adresa
angajatorului i anexai contractul)
You are or will be detached abroad by a Romanian employer (please mention the name and address
of the employer and attach the contract)
....
;
Suntei sau vei fi angajat de un angajator strin (menionai numele i adresa angajatorului i
anexai contractul)
You are or will be hired by a foreign employer (please mention the name and address of the
employer and attach the contract)

;
Vei desfura activitate independent (menionai tipul activitii i locul unde se desfoar
activitatea)
You are going to perform a self-employment activity (please mention the type of activity and the
place where the activity is performed)
.
.
F. Relaii familiale
Family relations
Prsesc Romnia mpreun cu dvs. i se afl n ntreinerea dvs:
There are leaving Romania with you and are depending on you
soul/soia
rezident n Romnia nerezident n Romnia statut nedeterminat
husband/wife
resident in Romania
non- resident in Romania
undetermined status
copilul minor
rezident n Romnia nerezident n Romnia statut nedeterminat
minor child
resident in Romania
non- resident in Romania
undetermined status
sau
or
o persoan
rezident n Romnia nerezident n Romnia statut nedeterminat
a person
resident in Romania
non- resident in Romania
undetermined status
Introducei numele, codul numeric personal/numrul de identificare fiscal i adresa unde locuiesc
aceste persoane:
Please mention the name, the personal/tax identification number and the address where these
persons live:
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................

n strintate deinei o locuin:


You have a dwelling place abroad

n proprietate (precizai adresa) .....


owned (please mention the address)
;
nchiriat (precizai adresa i perioada pentru care ai nchiriat locuina) .
rented (please mention the address and the period for which the dwelling place was rented)
.
G. Vei continua s obinei venituri din Romnia din:
You will continue to obtain income from Romania of

activiti dependente

activiti independente

dobnzi

dividende

employment activities
self-employment activities
interest
dividends
ctiguri de capital
venituri din cedarea folosinei bunurilor
pensii
capital gains
income from assigning the use of property
pension
altele (descriei) .
others (please describe)
niciun punct nu se aplic
none of the points apply

H. Informaii suplimentare
Additional information

intenionai s deinei n continuare o locuin n Romnia


you still intend to have a dwelling place in Romania

soul/soia,

copilul minor

sau
o persoan aflat n ntreinerea dvs.
husband/wife
minor child
or
a person depending on you
rmn n Romnia i nu prsesc ara mpreun cu dvs.
remain in Romania and are not leaving the country with you
avei autovehicul nregistrat
you have a registered vehicle
avei permis de conducere emis de autoritatea competent
you have a driving license issued by the competent authority
avei paaport emis de o autoritate competent
you have a passport issued by a competent authority
suntei asigurat la sistemul asigurrilor sociale de sntate
you are insured with a health insurance system
suntei asigurat la sistemul asigurrilor sociale
you are insured with a social security system

n strintate

n Romnia

abroad
din strintate
from abroad
din strintate
from abroad
din strintate
from abroad
din strintate
from abroad

in Romania
din Romnia
from Romania
din Romnia
from Romania
din Romnia
from Romania
din Romnia
from Romania

niciun punct din aceast seciune nu se aplic


none of the points in this section apply
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I. Alte informaii
Other information
Prezentai informaii suplimentare care considerai c sunt utile autoritii fiscale n vederea stabilirii
rezidenei dvs.fiscale n Romnia/alt stat
Please provide any additional information that you consider useful for the fiscal authority in order to
determine your fiscal residence in Romania/other country

...........................................
Data
Date

..............................................
Semntura solicitantului
Signature of applicant

J. Date de identificare ale mputernicitului (mputernicirea emis de o autoritate strin va fi nsoit


de o traducere autorizat n limba romn)
Identification data of the assignee (the empowerment issued by a foreign authority will be
accompanied by a certified translation into Romanian)

Reprezentantul/mputernicitul persoanei fizice


Agent/assignee of the individual
Nume i prenume: ......................................................................
Name and surname
Domiciliu fiscal: ..........................................................................
Fiscal domicile
Cod numeric personal: ...............................................................
Personal identification number
Semntura: ..................................................................................
Signature
Data: .............................................................................................
Date
Sub sanciunile aplicate faptei de fals n acte publice, declar c datele nscrise n acest formular sunt
corecte i complete.
Under the sanctions applied to forgery of public documents, I hereby declare that the data presented
in this document is correct and complete.
Persoana impozabil este obligat s aduc la cunotina organului fiscal orice schimbare aprut care
poate aduce modificri n ceea ce privete statutul rezidenei n Romnia
The taxpayer is required to notify the fiscal authority about any changes that can affect the residence
status in Romania.
__________________________________________________________________________________
n situaia n care plecarea dvs. se anuleaz i ai depus deja acest formular, v rugm s informai
autoritatea fiscal asupra schimbrii produse
If your departure is canceled and you have already filed this form, please notify the fiscal authority of
the change occurred
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INSTRUCIUNI
A) Persoana fizic rezident cu domiciliul n Romnia va anexa dup caz certificatul de
reziden fiscal eliberat de autoritatea competent a statului strin sau un alt document
eliberat de ctre o alt autoritate dect cea fiscal, care are atribuii n domeniul certificrii
rezidenei conform legislaiei interne a acelui stat, n original sau n copie legalizat,
nsoite de o traducere autorizat n limba romn.
B) La cererea autoritii fiscale romne, persoana fizic este obligat s prezinte documentele
solicitate de aceasta, nsoite de o traducere autorizat n limba romn i, dup caz, s
aduc clarificri adiionale.
C) Pentru informaiile prevzute la litera C din anex, organul fiscal va acorda asistena
necesar declarantului.
D) Chestionarul va fi completat cite, cu majuscule sau dup caz prin bifarea cu X a csuei
corespunzatoare. Se admite editarea i/sau completarea chestionarului n format Word.
Chestionarul va fi n format A4 i se completeaz pe ambele pri ale imprimatului.

INSTRUCTIONS
A) The resident individual residing in Romania shall enclose as the case may be the original
or the certified copy of the certificate of fiscal residence issued by the competent authority
of the foreign country or another document issued by an authority other than the fiscal one,
which is responsible for certifying the residence according to the national legislation of
that country, accompanied by a certified translation into Romanian.
B) At the request of the Romanian tax authority, the individual is required to submit the
documents requested by it, accompanied by a certified translation into Romanian and, as
the case may be, to make additional clarifications
C) For the information in letter C of the annex, the tax authority shall provide any necessary
assistance to the declarant.
D) The questionnaire will be legibly filled in, in capital letters or, as the case may be, by
ticking X in the appropriate box. The editing and/or completion of the questionnaire in a
Word format is accepted. The questionnaire will have an A4 format and is completed on
both sides.

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