FORM D – OTHER INCOME 
(this form must be used for the categories of income for which there is no specific form like employee income, selfemployed income, capital gains, director’s fees, etc.) 
EXEMPTION / APPLICATION OF TAX RATE PROVIDED BY THE CONVENTION 
 REFUND 
Article ___of the Convention for the avoidance of double taxation between Italy and___________ ITALIAN PAYER OF THE INCOME 
Person 	Surname Name / Company Name 	
Italian TIN 		
Residence 	Full address 	

DESCRIPTION OF THE INCOME RECEIVED1:_____________________________________ 
Payment date 	Amount of income gross of the Italian tax 	Amount of the tax paid in Italy 	Applicable tax rate according to the Convention 	Amount of the tax due 	Requested refund 	

						
						
				TOTAL 		

1 Please specify the category of income. 

FORM D – OTHER INCOME 
DECLARATION OF THE BENEFICIARY OR ITS AUTHORISED REPRESENTATIVE2 
The undersigned _________________________acting as ___________________________________________ 
Declares 
−	to reside / that the entity _____________________ is resident in _______________ pursuant to the Convention with _____________ for the tax period / periods ____________ ; 
−	to be / that the entity above mentioned is the beneficial owner of the income; 
−	not to have / that the above mentioned entity does not have a permanent establishment or a fixed base in Italy to which the income effectively connects; 
  to be / that the above mentioned entity is subject to tax for the specified income in the Country of residence; 
 NOT to be / that the above mentioned entity is NOT subject to tax for the specified income in the Country of 
residence (explain the reasons for exemption) ________________________________________________________________________________________ ; 
−	to comply with all other necessary requirement for applying the benefits granted by the Convention regarding the income received; 
−	that all information in this declaration is correct and complete, and that the undersigned shall communicate if one or more of the requirements described above ceases to be, as well as of any variations in the supplied data and information. 
Requests 
 exemption from Italian tax or application within the limits provided by the mentioned Convention; 
 refund of taxes regarding the income specified above;
− that the refund should be made according to the payment methods specified on the cover page. 
Place and date ________________ Signature ________________________

CERTIFICATION OF THE TAX AUTHORITY 
The Tax Authority of ____________________certifies that for the tax period/s _______ the beneficiary described above is resident in ___________________ according to Article ___ of the Convention with Italy and that the declarations given in this form are true to the best of the knowledge of this Tax administration. 
Date_________________ 	Signature and Office stamp 
 
2 The authorised representative is the delegated person authorised to submit the application and/or supply the declarations requested by the Convention on behalf of the beneficial owner (see cover page), on the basis of the document that grants the relative power of representation (the original copy of which must be attached).