Revue fiduciaire : actualité et information juridique, comptable, fiscale, sociale

BOFiP-FORM-000086-20170405

FORM-Annexes
000086-Formulaires

The same Form in French language is available in the BOI-FORM-000037 .

I) Identification of the income beneficiary
Name : Corporate name : ISIN code (if available, otherwise another code) : Full address of registered office : Number and date of authorisation of the supervisory authority : Name of the sub-fund :
II) Identification of the management company of the income beneficiary
Name : Corporate name : Full address of registered office :
III) Sworn statement
The undersigned, as the representative or management company of the income beneficiary, hereby certifies : - that the investment company or fund for which the withholding tax exemption is claimed, is the beneficial owner of the distributions - that the investment company or fund for which the withholding tax exemption is claimed complies, at the date hereof, with all the conditions set out in the table appended hereto - that the relevant amounts are not paid in a non-cooperative State or territory (NCST) within the meaning of Article 238-0 A of the General Tax Code
Date and place	Signature and stamp of the representative or management company
	. . .

IMPORTANT : In the third column, tick the box related to the Collective Investment Vehicle (CIV)'s situation for which the withholding tax exemption is claimed and carefully complete all the information requested in the fourth column. Otherwise this statement shall be invalidated.

Types of CIV	Characteristics required to benefit from the exemption	Information to provide
UCITS under Directive 2009/65/EC of the European Parliament and of the Council of 13 July 2009	Authorisation and prospectus	Authorisation number : .
	Key Investor Information Document (KIID)
"UCITS-like" AIFs	Authorisation	Authorisation number : .
	Depositary subject to prudential oversight and complying with the obligations laid down by Article 21 of Directive 2011/61/EU of the European Parliament and of the Council of 8 June 2011	Identification of the depositary : full contact details, name, address, identification and/or registration number : . . .
	Management company acting on behalf of the fund or, otherwise, technical and human resources at fund level to manage it	Identification of the management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of the statutory auditor : full contact details, name, address, identification and/or registration number : . . .
	Commitment to comply with the rules set out in the UCITS Directive
AIFs belonging to the category of "AIFs open to non-professional investors" other than "UCITS-like" AIFs	Authorisation	Authorisation number : .
	Depositary subject to prudential oversight and complying with the obligations laid down by Article 21 of Directive 2011/61/EU of the European Parliament and of the Council of 8 June 2011	Identification of the depositary : full contact details, name, address, identification and/or registration number : . . .
	Management company acting on behalf of the fund or, otherwise, technical and human resources at fund level to manage it	Identification of the management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of the statutory auditor : full contact details, name, address, identification and/or registration number : . . .
	Compliance with the criteria of Article 50 of Directive 2009/65/EC of the European Parliament and of the Council of 13 July 2009 : authorisation, oversight, cooperation, equivalent protection rules for unit-holders (division of risk) on UCITS asset mix requirements
AIFs "open to professional investors" and under certain conditions to non-professional investors	Authorisation or registration	Authorisation number : .
	Depositary subject to prudential oversight and complying with the obligations laid down by Article 21 of Directive 2011/61/EU of the European Parliament and of the Council of 8 June 2011	Identification of the depositary : full contact details, name, address, identification and/or registration number : . . .
	Management company acting on behalf of the fund or, otherwise, technical and human resources at fund level to manage it	Identification of the management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of the statutory auditor : full contact details, name, address, identification and/or registration number : . . .
AIFs equivalent to closed-end investment companies ("Sociétés d'Investissement à Capital Fixe - SICAF") governed by French law	Management company	Identification of the management company : full contact details, name, address, identification and/or registration number : . . .
	Depositary subject to prudential oversight and complying with the obligations laid down by Articles 22 et seq. of Directive 2009/65/EC of the European Parliament and of the Council of 13 July 2009	Identification of the depositary : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of the statutory auditor : full contact details, name, address, identification and/or registration number : . . .
AIFs equivalent to a real estate collective investment schemes ("Organismes de placement collectif immobilier - OPCIs") and professional OPCIs governed by French law	Authorisation	Authorisation number: .
	Depositary subject to prudential oversight and complying with the obligations laid down by Article 21 of Directive 2011/61/EU of the European Parliament and of the Council of 8 June 2011	Identification of the depositary : full contact details, name, address, identification and/or registration number : . . .
	Management company acting on behalf of the fund or, otherwise, technical and human resources at fund level to manage it	Identification of the management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of the statutory auditor : full contact details, name, address, identification and/or registration number : . . .
	Assets composed of at least 60 % of buildings built or bought to let (not for resale) directly or through shares in partnerships or unlisted companies and at least 10 % of liquidities (deposits, cash assets, liquid financial instruments)