Tax Invoice / ‫ﻓﺎﺗﻮﺭﺓ ﺿﺮﻳﺒﻴﺔ‬

Credit Note / ‫ﺍﺷﻌﺎﺭ ﺩﺍﺋﻦ‬

Tawuniya Insurance Co ‫ﺷﺮﻛﺔ ﺍﻟﺘﻌﺎﻭﻧﻴﺔ ﻟﻠﺘﺄﻣﻴﻦ‬

300002788510003
6507 3445 6507
Ath Thumamah Rd 3445 ‫ﻃﺮﻳﻖ ﺍﻟﺜﻤﺎﻣﺔ‬
Riyadh Ar Rabi District ‫ﺍﻟﺮﻳﺎﺽ ﺣﻲ ﺍﻟﺮﺑﻴﻊ‬
13315 13315
Saudi Arabia ‫ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬
Commercial registration number : 1010061695 1010061695 : ‫ﺭﻗﻢ ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬

Bill To Details: ‫ﺗﻔﺎﺻﻴﻞ ﺍﻟﻤﺸﺘﺮﻱ‬

Buyer Name ATQAN SASTMIZ CO ‫ﺷﺮﻛﺔ ﺍﺗﻘﺎﻥ ﺳﻴﺴﺘﻤﺰ ﺍﻟﻌﺮﺑﻴﺔ‬ ‫ﺍﺳﻢ ﺍﻟﻤﺸﺘﺮﻱ‬
Buyer VAT Number 310706830500003 310706830500003 ‫ﺭﻗﻢ ﺗﺴﺠﻴﻞ ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ ﻟﻠﻤﺸﺘﺮﻱ‬
Buyer Address 3539 8232 8232 3539 ‫ﻋﻨﻮﺍﻥ ﺍﻟﻤﺸﺘﺮﻱ‬
makkah al mukarramah ‫ﻃﺮﻳﻖ ﻣﻜﺔ ﺍﻟﻤﻜﺮﻣﺔ ﺍﻟﻒ‬
AlKharj Al Rabwah Dist ‫ﺍﻟﺨﺮﺝ ﺣﻲ ﺍﻟﺮﺑﻮﺓ‬
59855 Al Rabwah Dist ‫ﺣﻲ ﺍﻟﺮﺑﻮﺓ‬
Saudi Arabia ‫ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬
Buyer Other ID Other ID : 7017741252 7017741252 : ‫ﻫﻮﻳﺔ ﺗﻌﺮﻳﻒ ﺃﺧﺮﻯ‬ ‫ﺭﻗﻢ ﺗﻌﺮﻳﻒ ﺍﻟﻤﺸﺘﺮﻱ‬
Buyer Email ID joud.a@isarabia.com

Invoice Details: ‫ﺗﻔﺎﺻﻴﻞ ﺍﻟﻔﺎﺗﻮﺭﺓ‬ Policy Details: ‫ﺗﻔﺎﺻﻴﻞ ﻭﺛﻴﻘﺔ ﺍﻟﺘﺄﻣﻴﻦ‬

Invoice No. A01-TC-970398 ‫ﺭﻗﻢ ﺍﻟﻔﺎﺗﻮﺭﺓ‬ Policy No. 28365859 ‫ﺭﻗﻢ ﺍﻟﻮﺛﻴﻘﺔ‬
Invoice Date and Time 2024-02-20 11:02:27 ‫ﺗﺎﺭﻳﺦ ﻭﻭﻗﺖ ﺍﻟﻔﺎﺗﻮﺭﺓ‬ Policy Period 04-JAN-24 - 23-APR-24 (‫ ﺍﻟﻰ‬- ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﺛﻴﻘﺔ )ﻣﻦ‬
Preceding Invoice Number 82517384 ‫ﺭﻗﻢ ﺍﻟﻔﺎﺗﻮﺭﺓ ﺍﻟﺴﺎﺑﻘﺔ‬ Endorsement No. 11 ‫ﺭﻗﻢ ﺍﻟﻤﻠﺤﻖ‬
Internal Reference No. 126278738 ‫ﺭﻗﻢ ﺍﻟﻤﺮﺟﻊ ﺍﻟﺪﺍﺧﻠﻲ‬ Endorsement Effective Date 04-JAN-24 ‫ﺑﺪﺀ ﺗﻐﻄﻴﺔ ﺍﻟﻤﻠﺤﻖ‬
Internal Reference Date 2024-01-04 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﺮﺟﻊ ﺍﻟﺪﺍﺧﻠﻲ‬ Certificate No. 0 ‫ﺭﻗﻢ ﺍﻟﺸﻬﺎﺩﺓ‬
Supply Date 2024-01-01 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻮﺭﻳﺪ‬ Risk No. 1 ‫ﺭﻣﺰ ﺍﻟﻘﻄﺎﻉ‬
Supply End Date 2024-01-31 Risk Name RIYADH ‫ﺍﺳﻢ ﺍﻟﻘﻄﺎﻉ‬
Invoice Transaction Code 0100000 ‫ﺭﻣﺰ ﺍﻟﻤﻌﺎﻣﻠﺔ‬
Special Billing Agreement Not Applicable
Source Code CM-559445-EN ‫ﺭﻗﻢ ﺍﻟﻤﺼﺪﺭ‬
Amendment of the supply value which is pre-agreed upon between the supplier
Reason for Issuing Credit Note ‫ﺗﻌﺪﻳﻞ ﻗﻴﻤﺔ ﺍﻟﺘﻮﺭﻳﺪ ﺍﻟﻤﺘﻔﻖ ﻋﻠﻴﻪ ﻣﺴﺒﻘﺎً ﺑﻴﻦ ﺍﻟﻤﻮﺭﺩ ﻭﺍﻟﻤﺴﺘﻬﻠﻚ‬ ‫ﺳﺒﺐ ﺍﺻﺪﺍﺭ ﺍﺷﻌﺎﺭ ﺩﺍﺋﻦ‬
and consumer

Details / ‫ﺗﻔﺎﺻﻴﻞ‬ Amount in SAR / ‫ﺍﻟﻤﺒﻠﻎ ﺑﺎﻟﺮﻳﺎﻝ ﺍﻟﺴﻌﻮﺩﻱ‬

Tax treatment applied to Total Amount
Sr. No. Nature of goods or services VAT Category Quantity Unit Price Amount Discount Taxable Value VAT Rate VAT Amount
the supply inclusive of VAT
‫ﺭﻗﻢ‬ ‫ﺍﻟﻤﻌﺎﻣﻠﺔ ﺍﻟﻀﺮﻳﺒﻴﺔ ﺍﻟﻤﻨﻄﺒﻘﺔ ﻋﻠﻰ‬ ‫ﺍﻟﻘﻴﻤﺔ ﺍﻟﺨﺎﺿﻌﺔ‬
‫ﻃﺒﻴﻌﺔ ﺍﻟﺴﻠﻊ ﺃﻭ ﺍﻟﺨﺪﻣﺎﺕ‬ ‫ﻓﺌﺔ ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ‬ ‫ﻛﻤﻴﺔ‬ ‫ﺳﻌﺮ ﺍﻟﻮﺣﺪﺓ‬ ‫ﺍﻟﻤﺒﻠﻎ ﺍﻹﺟﻤﺎﻟﻲ‬ ‫ﺧﺼﻢ‬ ‫ﻧﺴﺒﺔ ﺍﻟﻀﺮﻳﺒﺔ‬ ‫ﻗﻴﻤﺔ ﺍﻟﻀﺮﻳﺒﺔ‬ ‫ﺍﻟﻤﺒﻠﻎ ﺍﻻﺟﻤﺎﻟﻲ‬
‫ﺍﻟﺘﺴﻠﺴﻞ‬ ‫ﺍﻟﺘﻮﺭﻳﺪ‬ ‫ﻟﻠﻀﺮﻳﺒﺔ‬

1 COMPULSORY MEDICAL . Standard rate ‫ﺍﻟﻤﻌﺪﻝ ﺍﻷﺳﺎﺳﻲ‬ 1.000 7,039.0000 7,039.00 0.00 7,039.00 15.00 1,055.85 8,094.85
Payment Details / ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺪﻓﻊ‬ Total Amount in SAR / ‫ﺍﻟﻤﺒﻠﻎ ﺑﺎﻟﺮﻳﺎﻝ ﺍﻟﺴﻌﻮﺩﻱ‬

Payment Due / ‫ﺍﺳﺘﺤﻘﺎﻕ ﺍﻟﺪﻓﻊ‬ 8,094.85 Saudi Riyal Total Taxable Amount / ‫ﺇﺟﻤﺎﻟﻲ ﺍﻟﺨﺎﺿﻊ ﻟﻠﻀﺮﻳﺒﺔ‬ 7,039.00
Payment Terms / ‫ﺷﺮﻭﻁ ﺍﻟﺪﻓﻊ‬ 04-JAN-24 Invoice Discount / ‫ﺇﺟﻤﺎﻟﻲ ﺍﻟﺨﺼﻢ‬ 0.00
(Installment Due Date / ‫)ﺗﺎﺭﻳﺦ ﺍﺳﺘﺤﻘﺎﻕ ﺍﻟﺪﻓﻌﺔ‬ Invoice Amount Without VAT / ‫ﻣﺒﻠﻎ ﺍﻟﻔﺎﺗﻮﺭﺓ ﺑﺪﻭﻥ ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ‬ 7039.00
Mode of Payment / ‫ﻃﺮﻳﻘﺔ ﺍﻟﺪﻓﻊ‬ Mutually defined / ‫ﻣﺤﺪﺩﺓ ﺑﺸﻜﻞ ﻣﺘﺒﺎﺩﻝ‬ Total VAT Amount / ‫ﺇﺟﻤﺎﻟﻲ ﻣﺒﻠﻎ ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ‬ 1,055.85
Invoice Amount With VAT / ‫ﻣﺒﻠﻎ ﺍﻟﻔﺎﺗﻮﺭﺓ ﻣﻊ ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ‬ 8,094.85

Notes
‫ﻣﻠﺤﻮﻇﺎﺕ‬

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