STATEMENT OF CONTRIBUTIONS/WITHDRAWALS (For Non-Singapore Citizen Employee Ceasing Employment In Singapore And Seeking Tax Clearance). You may take 6 minutes to fill up this form. Please get ready your SRS contribution/withdrawal statement from the SRS operator.
Section A: SRS Member’s Particulars
Full Name: ______NRIC/FIN/Passport No. * ______Residential Address: ______
Section B: SRS Member’s Account Details
SRS’s Account Number: ______Transferred To : ______/ Date A/C Closed/Transferred : ______
(Note: When there is a transfer of account during the year, the statement of contributions/withdrawals from previous operator is required to be furnished.)
To complete the following ONLY if SRS Account was opened in the preceding year or in the current year
Date Account Opened : ______Date of 1St Contribution : ______Retirement Age as at : ______date of 1st contribution
Section C: Contributions/Withdrawals Made in the Current Year As At To Date
Contributions: Total Amount Contributed : S$ ______SRS Contribution Cap : S$______
Withdrawals:Date / Withdrawn
Amount ($) / Taxable
Component ($) / Withholding Tax ($) / 5% Penalty Imposed? / Reason for Withdrawal / Type of Withdrawal
Yes/No * / Full/Partial *
Yes/No * / Full/Partial *
Yes/No * / Full/Partial *
TOTAL
Section D : Contributions/Withdrawals Made in the Preceding Year As At 31 Dec of That Year
( To be completed only if the request of Statement is during the period from Jan to Apr)
Contributions: Total Amount Contributed : S$______SRS Contribution Cap : S$______
Withdrawals:
Date / Withdrawn
Amount ($) / Taxable
Component ($) / Withholding Tax ($) / 5% Penalty Imposed? / Reason for Withdrawal / Type of Withdrawal
Yes/No * / Full/Partial *
Yes/No * / Full/Partial *
Yes/No * / Full/Partial *
TOTAL
Section E : Undertaking
By SRS Operator:
We certify that the information given in this form is correct. In the event that the abovenamed SRS Member makes a withdrawal from his SRS account of an amount up to the amount that he has contributed in the current year, and subject to the provision of the undertaking below by the SRS Member, we undertake to withhold tax at the non-resident tax rate of 20% on such sums withdrawn by the SRS Member and to pay over the tax within 10 days to Comptroller of Income Tax.
Name of SRS Operator / Name of Officer/Designation / Signature / Contact No / Date
By SRS Member:
In consideration of the tax relief granted to me by the Comptroller of Income Tax for contributions made to my SRS account in the current year, I hereby authorise and instruct the SRS Operator that, in the event that I need to withdraw the same within the current year, to withhold tax at non-resident tax rate of 20%on such sums withdrawn, and to pay the amount so withdrawn to the Comptroller of Income Tax.
Full name of SRS Member / Signature / Contact No / Date
F04-01 * Delete whichever is not applicable