5002-EN - France in the United Kingdom

@ Internet-DGIRecipient’s nameFor use by theforeign taxauthorityCALCULATION AND REPAYMENT OF5002-ENWITHHOLDING TAX ON INTERESTAttachment to Form 500012816*01YOU ARE A LEGAL ENTITYIf you are eligible for the exemption under Directive 2003/49/EC of3 June 2003 (article 119 quater of the CGI) make sure the Box III is completedI) To be completed by the recipient Please make sure that you complete Boxes I, II, III and VII of Form 5000French payerDescription of incomePaymentdateNumberofsecuritiesUnit value€II) To be completed by the payinginstitutionPlease make sure that Box V of Form 5000has been completedTax due underthe applicabletax treaty€(column 3 xcolumn 4 x treatyrate)Tax calculationAmount ofFrench tax paid€(column 3 xcolumn 4 xdomestic rate)Amountreclaimed€(column 5 –column 6)1 2 3 4 5 6 7TOTALSIII) Declaration of recipient applying for an exemptionunder Directive 2003/49/EC (art. 119 quater of the CGI)AMOUNT DUE(column 5 –column 6)AMOUNT TO BE REPAID(column 6 –column 5) I hereby certify that I meet the holding requirements stipulated in Directive 2003/49/EC of 3 June 2003 (art. 119 quater of theCGI) and, consequently, I am applying for an exemption from the withholding tax on interest collected from French sources .………………………………………………...Date and placeSignature of beneficiary or his/her legal representative

@ Internet-DGIRecipient’s nameTo be kept bythe recipientCALCULATION AND REPAYMENT OF5002-ENWITHHOLDING TAX ON INTERESTAttachment to Form 500012816*01YOU ARE A LEGAL ENTITYIf you are eligible for the exemption under Directive 2003/49/EC of3 June 2003 (article 119 quater of the CGI) make sure the Box III is completedI) To be completed by the recipient Please make sure that you complete Boxes I, II, III and VII of Form 5000French payerDescription of incomePaymentdateNumberofsecuritiesUnit value€II) To be completed by the payinginstitutionPlease make sure that Box V of Form 5000has been completedTax due underthe applicabletax treaty€(column 3 xcolumn 4 x treatyrate)Tax calculationAmount ofFrench tax paid€(column 3 xcolumn 4 xdomestic rate)Amountreclaimed€(column 5 –column 6)1 2 3 4 5 6 7TOTALSIII) Declaration of recipient applying for an exemptionunder Directive 2003/49/EC (art. 119 quater of the CGI)AMOUNT DUE(column 5 –column 6)AMOUNT TO BE REPAID(column 6 –column 5) I hereby certify that I meet the holding requirements stipulated in Directive 2003/49/EC of 3 June 2003 (art. 119 quater of theCGI) and, consequently, I am applying for an exemption from the withholding tax on interest collected from French sources .………………………………………………...Date and placeSignature of beneficiary or his/her legal representative

@ Internet-DGIReport du nom du créancierFor use by theFrench taxauthorityLIQUIDATION ET REMBOURSEMENT5002-ENDU PRÉLÈVEMENT À LA SOURCE SUR INTÉRÊTSAnnexe au formulaire n°5000 12816*01VOUS ETES UNE PERSONNE MORALESi vous pouvez bénéficier de l’exonération prévue par la directiven° 2003/49/CE du 3 juin 2003 (art. 119 quater du CGI) N’oubliez pas de compléter le cadre IIII) A remplir par le créancier II) A remplir par l’établissement payeurN’oubliez pas de compléter les cadres I, II, III et VII du formulaire n°5000Débiteur françaisDésignation du revenuDate demise enpaiementNombrede titresValeurunitaireen €N’oubliez pas de compléter le cadre V duformulaire n°5000Montant del’impôt exigibleen applicationde la conventionen €(col 3 x col 4 xtaux convention)Liquidation de l’impôtMontant del’impôt françaispayéen €(col 3 x col 4 xtaux interne)Montant dudégrèvementdemandéen €(col 5 – col 6)1 2 3 4 5 6 7TOTAUXIII) Déclaration du créancier demandant le bénéfice dela directive n° 2003/49/CE (art. 119 quater du CGI)A PAYERCol 5 – Col 6A REMBOURSERCol 6 – col 5 Je déclare satisfaire aux conditions de participation prévues par la directive n° 2003/49/CE du 3 juin 2003 demande enconséquence l’exonération de retenue à la source au titre des intérêts de source française perçus .………………………………………………...Date and placeSignature du créancier ou de son représentant légal