Nr.

i data nregistrrii la autoritatea fiscal*

Number and date of registrton at the tax authorty*

*Numr de nregistrare ca operator de date cu caracter personal: 259

Registration number as personal data operator: 759

Chestionar pentru stabilirea rezidenfei fiscale a persoanei fizice la plecarea din Romnia
Set of questons or determining the Jiscl resdence olthe ndivdual when levng Romana

A. Date de identificare le persoanei fizice rezidente/ nerezidente care pleac din Romnia
Identificaton data of the resident/non-resdent indvduat levng Romana

Nume i prenume .. 5V eu. .9.4. LV. .6.-Ip-qH c etlen i e/r.{a1i onal itate . . . Ro
NA
.. . 1L . .

Narne and surname C i t iz en s h ip/Na tio nali ty

Cod Numeric PersonallllF JtTjqf L1h ottE

Pers onal/Tax identifi cation numb er

Data nater (zz.ll.aaaa) ....

Date of birth (dd/mm/yyyy)
.,1.1./,a3j.13 -t+. , Anur nscar
Fiscl year

Stare civil: El cstorit() fl necstorit() ! divor{at() ! vduv()

Civil status married single divorced widower/widow

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

Address n/ outsde Roman nd period of stying outsde Romna

Adresa din Romnia (nainte de a prsi Romnia)

Address in Romania (bere leaving Romnia)

VrouUotl6' 'NQ"Z
E adresa de domic iI iu .......0..9'. 99f.f.4..... lV.N.q .sEue{'^J , StR.

I adresa locuinfei permanente

permanent home address

Statul n care ve{i locui/se solicita rezidenfa t-t

Country you will live in/r which residence is requested
- r-,t I
Adresa, telefonul i adresa de e-mail din strintat" ......Ktl.h.' LA&G,C V RqIH O
Address, phone and e-mail address from abroad

_rsOsqi lq, i\lrFAlg 9, t33?3?gl?{a!:!!! ucr"su "{ il .nn

Data plecri i d in Rom nia (zz.n.aauu) ...... ...... *.6.,..q .,.*pl-

Date of departurefrom Romania (dd/mm/yyyy)

Ct timp preconizali c vefi petrece n afara Romniei? . It P_Erslli iS

qlr+.l ul U rr_
JE u N .kNl" 7
How long do you intend to stay outside Romania?

C. Declara{ie privind rezidenla fiscal

Declrton on fiscl resdence
a) Sunteli rezident fiscal n Romnia la data plecrii din Romnia? X DA trNU
Are you afiscal resident of Romania when leaving Romania? YES NO

b) Sunteti rezident fiscal ntr-un stat cu care Romnia are ncheiat DA NU

o convenfie de evitare a dublei impuneri? YES NO
Are you afiscal resident of a country that has a conventionfor
the avodance of double taxation concluded with Romania?

In caz afirmativ, avefi obliga{ie fiscal integral n acel stat? oe !NU

If yes, do you have afull tax liability in that country? YES NO

c) Suntefi rezident fiscal ntr-un stat cu care Romnia nu are ncheiat !DA X r.u
o convenfie de evitare a dublei impuneri? YES NO
Are you afiscal resident of country not having a conventionfor
the avoidance of double taxation concluded with Romania?

Pentru aplicarea prevederilor conven{iei de evitare a dublei impuneri persoana frzic romn are
obligatia s prezinte certificatul de reziden{ fiscal emis de autoritatea competent a statului strin
care l consider rezident fiscal i cu care Romnia are ncheiat convenfie.
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 reign country that considers him/her to be its fiscal resident and that has a
convention concluded with Romnia.

D. Motivul plecrii din Romnia

Reson for leavng Romna
! Sunte,ti detaat n strintate de un angajator romn;
You have been detached abroad by a Romanian employer
tr Sunteli angajat n strintate de un angajator strin;
You have been hired abroad by areign employer
fl lesfurafi activitate independent n strintate;
You are pedormng a self-employment activity abrod
tr Suntefi pensionar;
You are retired
! Studiati, predali sau efectua{i cercetare ntr-o institufie de nvtmnt strin sau ntr-un institut
strin de cercetare (menfionafi numele i adresa institutiei)
You are studying, teaching or doing research in a reign educational institution or research
institute (please mention the name and address of the institution).

! altele (explicafii) ......

others (please explatn)

I
 E. Relalia de angajare
E mpl oy m e nt r e I tio n s h p

Dac vefi fi angajat sau ve{i desura activitate n strintate, bifafi csula care vi se aplic:
If you are going to be hired or pedorming activity abroad, please tick the appropriate box

! Sunte{i sau ve{i fi detaat n strintate de un angajator romn (menfionafi numele i adresa
angajatorului i anexafi 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)

tr Suntefi sau vefi fr angajat de un angajator strin (menfionafi numele i adresa angajatorului i
anexafi contractul)
You are or will be hired by aforeign employer (please mention the name and address of the
employer nd attach the contract)

fr V"[i desfura activitate independent (menionafi tipul activitlii i locul unde se desfoar
activitatea)
You are going to perform a self-employment ctvity (please mention the type of activity and the

bi

F. Relalii fa
Fam reltons N S? 4rUiCA, r,,litt U'NUL iN PUUCIgUE E't'{41 JoS
Prsesc Romnia mpreun cu dvs. i se afl n ntre{inerea dvs:
There are leaving Romani with you and are depending on you
! so,tul/sofia tr rezident n Romnia ! nerezident n Romnia tr statut nedeterminat
husband/wife resident in Romana non- resident in Romania undetermined status
! copilul minor tr rezident n Romnia ! nerezident n Romnia tr statut nedeterminat
minor child resident in Romania non- resident in Romania undetermined status
sau
or
E opersoanL >! rezidentnRomnia t nerezidentnRomnia tr statutnedeterminat
a person resident in Romania non- resident in Romqnia undetermined status

Introducefi numele, codul numeric personal/numruI de identificare fiscal i adresa unde locuiesc
aceste persoane:
Please mention the name, the personal/tax identffication number and the address where these
persons live:

9
In strintate detinefi o locuin{:
You have a dwelling place abroad

tr n proprietate (preciza{i adresa) ....

owned (please mention the address)

fl nchiriat (precizafi adresa i perioada pentru care afi nchiriat locuin)

rented (please rnention the address nd the period for which the dwelling place was rented)

tk lsPoilris l LRo viRc,itilq Req H fp,, ir?m 3, wtvt * ,

t{ELiMllTll-
G. veli continua s ob{inefi venturi din Romnia din:
Yoa wll continue to obtin incomefroru Romn of

fl activitti dependente ! activitti independente tr dobnzi ! dividende

employment activities
n ctiguri de capital Il
capital gains
! altele (descrieli)
others (please describe)
self-employment activities interest dividends
venituri din cedarea folosin{ei bunurilor ! pensii
income from assigning the use of property pension

flniciun punct nu se aplic

none of the points apply

H. Informafii suplimentare
Addto n al info rm to n

tr inten{ionafi s detinefi n continuare o locuin! n Romnia

you still intend to have dwelling place in Romania

! soful/so{ia, ! copilul minor sau E o persoan aflat, n ntrefinerea dvs

husband/wife minor child or q person depending on you
rmn n Romnia i nu prsesc lara mpreun cu dvs.
remain in Romania and are not leaving the country with you

avefi autovehicul nregistrat ! n strintate tr n Romnia

you have a registered vehicle broad in Romania
avefi permis de conducere emis de autoritatea competent tr din strintate fi,din Romnia
you have a driving license issued by the cornpetent authority from abroad from Romania
avefi paaport emis de o autoritate competent ! din strintate X,in Romnia
you have a passport issued by a competent authority .from abrod from Romania
sunte{i asigurat la sistemul asigurrilor sociale de sntate frain strintate tr din Romnia
you are insured with a health insurance systern from abroad from Romania
suntefi asigurat la sistemul asigurrilor sociale f,,Oin strintate tr din Romnia
you are insured with a social security system .from abroad from Romani

tr niciun punct din aceast sec{iune nu se aplic

none of the points in this section apply

l0
I. Alte informafii
Other nrmaton

Prezentafi informa{ii suplimentare care considerafi c sunt utile autorittii fiscale n vederea stabilirii
rezidenfei dvs.fiscale n Romnia/alt stat
Please provide any additional information that you consider useful for the fiscal authority in order to
determine yourfiscal residence in Romania/other country

&8 0b a.o4T
Data
dts
Semntura solicitantului
Date Signature of applicant

J. Date de identificare ale imputernicitului (mputernicirea emis de o autoritate strin va fi nso{it

de o traducere autorizat n limba romn)
Identiftcton dt of the ssgnee (the empowerment issued by a reign authority will be
accompnied by a certified translation into Romanian)

R"p..r.ntantuVmputernicitul 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:......... a8.03 W+
Date

Sub sanc{iunile aplicate faptei de fals n acte publice, declar c datele nscrise n acest formular sunt
corecte i complete.
Under the sanctions applied to rgery of public documents, I hereby declare that the data presented
in this document is correct and complete.

Persoana impozabil este obligat s aduc la cunotinla organului fiscal orice schimbare aprut care
poate aduce modificri n ceea ce privete statutul rezidenfei n Romnia
The taxpayer is required to notifi the fiscal authority qbout any changes that can affect the residence
status in Romania.

n situafia n care plecarea dvs. se anuleaz, i afi depus deja acest formular, v rugm s informafi
autoritatea fiscal asupra schimbrii produse
If your departure is canceled and you have alredy filed th rm, please notifu the fiscal authority of
the change occurred

ll
 INSTRUCTITINI

A) Persoana fizic, rezident cu domiciliul n Romnia va anexa dup, caz certificatul de

rezidenf fiscal eliberat de autoritatea competent a statului strin sau un alt document
eliberat de ctre o alt autoritate dect cea fiscal, care are atribufii n domeniul certificrii
rezidenei conform legislafiei interne a acelui stat, n original sau n copie legalizat,
nsofite de o traducere autorizat n limba romn.
B) La cererea autoritfii fiscale romne, persoana fizic este obligat s prezinte documentele
solicitate de aceasta, nsofite de o traducere autorizat n limba romn i, dup caz, s
aduc clarificri adifionale.
C) Pentru informatiile prevzute la litera C din anex, organul fiscal va acorda asistenla
necesar declarantului.
D) Chestionarul va fi completat citel, cu majuscule sau dup caz prin bifarea cu ,,X" a csufei
corespunzatoare. Se admite editarea i/sau completarea chestionarului n format Word.
Chestionarul va fi n format A4 i se completeaz pe ambele prli ale imprimatului.

INSTRUCTIONS

A) The resident individual residing in Romnia shall enclose as the case rnay be the orignal
or the certified copy of the certificate offiscal residence issued by the competent authority
of the reign country or another document issued by an authority other than the fiscal one,
which is responsible r 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 subrnit the
documents requested by it, accompnied 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 editng and/or completion of the questionnaire in a
IVord rmat is accepted. The questionnaire will have an A4 format and is cornpleted on
both sides.

12