外匯收支或交易申報書（結購外匯專用）

Declaration Statement of Foreign Exchange Receipts and Disbursements or Transactions (For settlement of purchase only)

結購外匯直接匯出 □結購外匯轉匯國內他行 □結購外匯存入外匯存款

Direct outward remittance Remittance into another domestic bank Deposit into foreign currency deposit account

結購外幣現鈔或旅行支票 □其他（請說明）:

Foreign currency cash or traveler's check Others (please indicate):

注意（Notices）： 申報義務人務請審慎據實申報，申報後除有「外匯收支或交易申報辦法」第13條之情形外，不得要求更改申報書內容。 The Declarant shall exercise deliberation in making a truthful declaration. Except for the situations under Article 13 of the Regulations Governing the Declaration of Foreign Exchange Receipts and Disbursements or Transactions, the declarant may not request to make changes to the contents of the Declaration Statement after the declaration is made. 申報義務人申報不實，依管理外匯條例第20條第1項規定，處新臺幣3萬元以上，60萬元以下罰鍰。 Untruthful declarations are subject to a fine of at least New Taiwan dollars 30,000 and no more than New Taiwan dollars 600,000 pursuant to Paragraph 1, Article 20 of Foreign Exchange Control Act. 本申報書匯款金額不得塗改，其餘部分如經塗改，應由申報義務人在塗改處簽章，否則本申報書不生效力。 The remittance amount stated in this Declaration Statement shall not be altered. If any other section stated in this Declaration Statement is altered, the declarant shall affix his/her seal or signature next to the alteration; failure to do so shall render this Declaration Statement invalid. 一. 申報日期（Date of Declaration）: 年(Yr) 月(Mo) 日(Dy)

二. 申報義務人（Declarant）:

三. 申報義務人登記證號（Declarant's ID No.）:

□1.公司、有限合夥、行號：統一編號（Company , Limited Partnership, or firm：Uniform No.）

□2.團體、辦事處及事務所（Association, representative’s office）：

統一編號（Uniform No.）:

其他無統一編號者：設立登記主管機關:

Others without Uniform No.：Competent authority for establishment and registration:

登記證號（Registration No.）:

□3.個人（國民身分證、居留證效期一年以上）

Individual ( Citizen's ID Card or Resident Certificate with a validity for at least one year)

身分證號或統一證號（ID No.）：

出生日期（Date of birth）: 年(Yr) 月(Mo) 日(Dy)

居留證發給日期（Date of issuance）: 年(Yr) 月(Mo) 日(Dy)

居留證到期日期（Date of expiry） : 年(Yr) 月(Mo) 日(Dy)

□4.非居住民（護照、入出境許可相關證明文件、居留證效期未滿一年）

Non-resident（Passport, Entry and Exit Permit or related document, or Resident Certificate with a validity of less than one year）

出生日期（Date of birth）: 年(Yr) 月(Mo) 日(Dy)

國別（Nationality）：

護照或證照號碼（Passport or Certificate No.）：

居留證發給日期（Date of issuance）: 年(Yr) 月(Mo) 日(Dy)

居留證到期日期（Date of expiry） : 年(Yr) 月(Mo) 日(Dy)

四. 外匯支出或交易性質（性質超過一種者，應加填每種性質之金額）:

Nature of foreign exchange disbursements or transactions (if more than one category, indicate amount for each category)

□進口貨品價款或償付非居住民服務支出 (應具體詳填性質)

Disbursements of the import of goods or for the provision of services by non-residents
(indicate in detail the nature of the transaction)

□ 其他匯出款項(應具體詳填性質)

Other outward remittance (indicate in detail the nature of the transaction)

五. 匯款金額 Amount remitted:

六. 受款地區國別 Remittance to (country)：

銀行業或外匯證券商 負責輔導申報義務人員 簽章 Signature of Banking Enterprise or DSF Personnel Advising the Declarant 茲具結以上所報均屬真實

The undersigned hereby declares that all information provided above is true and correct.

此 致To

中央銀行Central Bank of the Republic of China (Taiwan)

申報義務人及其負責人簽章 Signature of the Declarant and its responsible person

地址 Address:	電話Tel:

以下各欄由銀行業或外匯證券商填寫

The banking enterprise or DSF (Domestic Security Firm Approved To Conduct Foreign Exchange Business) shall fill out the section below

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送件編號Case No.:	銀行業或外匯證券商簽章及日期 Banking Enterprise or DSF seal and date:

保存期限至少五年(Retained for at least five years) O-312 _110.07 外匯水單編號 Foreign Exchange Memo No.: