![](data:image/png;base64,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)
CỘNG HOÀ XÃ HỘI CHỦ NGHĨA VIỆT NAM
Độc lập - Tự do - Hạnh phúc
TỜ KHAI CÁC KHOẢN THU VỀ HOA HỒNG DẦU KHÍ, TIỀN ĐỌC
VÀ SỬ DỤNG TÀI LIỆU DẦU KHÍ
[01] Kỳ tính thuế: Lần phát sinh ngày ... tháng ... năm ...
[02] Lần đầu □ [03] Bổ sung lần thứ: ...
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
[04] Tên người nộp thuế: .............................................................................................
[05] Mã số thuế người nộp thuế:
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAZCAYAAAAv3j5gAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACRSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdsFXXMo5L1nj5H7jWrzMAAAAAElFTkSuQmCC)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
[06] Hợp đồng dầu khí lô: .............................................................................................
[07] Mã số thuế hợp đồng dầu khí:
[08] Địa chỉ nhà điều hành PSC: ...................................................................................
[09] Quận/huyện: .................................. [10] Tỉnh/Thành phố: ......................................
[11] Điện thoại: ................ [12] Fax: ............................ [13] E-mail: ...........................
[14] Tên đơn vị được uỷ quyền [ ] hoặc Đại lý thuế [ ]: ..........................................
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABoAAAAaCAYAAACpSkzOAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAACWSURBVEhLvc2xDcNAAALA339pW+hwJuBzEg0FnH97LufnuSXbLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy7oPVetl3Qei/bLmi9l20XtN7Ltgta72XbBa33su2C1nvZdkHrvWy74Csu5ZwXcDI+MwU5hDkAAAAASUVORK5CYII=)
[15] Mã số thuế đơn vị được uỷ quyền/đại lý thuế :
[16] Địa chỉ: ...................... [17] Quận/huyện: ............... [18] Tỉnh/Thành phố: ............
[19] Điện thoại: ................ [20] Fax: ............................ [21] E-mail: ...........................
[22] Hợp đồng uỷ quyền hoặc Hợp đồng đại lý thuế, số: ............. ngày .....................
STT | Chỉ tiêu | Mã chỉ tiêu | Đơn vị tính | Số tiền |
1 | Tiền thu hoa hồng chữ ký | [23] | USD | |
2 | Tiền thu hoa hồng phát hiện thương mại dầu, khí | [24] | USD | |
3 | Tiền thu hoa hồng sản xuất | [25] | USD | |
4 | Tiền đền bù do không thực hiện đầy đủ cam kết tối thiểu của nhà thầu trong các Hợp đồng dầu khí | [26] | USD | |
5 | Tiền đọc và sử dụng tài liệu dầu khí (100%) | [27] | USD | |
5.1 | Tiền đọc và sử dụng tài liệu dầu khí nộp NSNN | [28] | USD | |
Tôi cam đoan số liệu khai trên là đúng và chịu trách nhiệm trước pháp luật về số liệu đã khai./.
NHÂN VIÊN ĐẠI LÝ THUẾ Họ và tên:.............................. Chứng chỉ hành nghề số:....... | ..., ngày....... tháng....... năm....... NGƯỜI NỘP THUẾ hoặc ĐẠI DIỆN HỢP PHÁP CỦA NGƯỜI NỘP THUẾ (Chữ ký, ghi rõ họ tên; chức vụ và đóng dấu (nếu có)/Ký điện tử) |
Ghi chú:
- Chỉ tiêu [04]: Tên người nộp thuế là Tập đoàn Dầu khí Việt Nam (Lô...).
Nguồn: Thông tư 80/2021/TT-BTC