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BOI-FORM-000080-20150812
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FORMULAIRE - INT - Modèle d'attestation en Anglais à produire par les organismes canadiens en matière de dividendes (convention fiscale franco-canadienne)

(article 29, paragraph 7, subparagraph b)

For the exemption of French tax on French dividends paid to these organizations operated in Canada exclusively to administer or provide benefits from one or more pension or retirement plans and that are exempt from tax, in accordance with the France-Canada Tax Convention of May 2, 1975, as amended by the Protocol dated November 30, 1995.

The undersigned…………………………………………………………………………………………………………..…...

…………………………. (name and address of trustee/administrator) hereby certifies that the organization

…………………………………………………………………………….(name and address) constituted in Canada

the……………………………………………., established in Canada and is :

(a) a trust governed by a Canadian registered pension plan (RPP) or a pension corporation whose

- plan registration number is……………….., and

- the account number of the trust or pension corporation is………… ; or

the undersigned…………………………………………………………………………………………………... (name and

address of trustee/administrator of the corporate trustee) hereby certifies that the organization

………………………………………………………………………(name and address) constituted in Canada the

………………………….., established in Canada and is (or the organizations are)

(b) a registered retirement savings plan(s) for which the corporate trustee is the issuer of the

plan(s) and

- the specimen plan identification number is………….., and

- the account number of the corporate trustee is……………. ; or

(c) a registered retirement income fund(s) for which the corporate trustee is the issuer of the fund(s)

and

- the specimen fund identification number is ……………, and

- the account number of the corporate trustee is ……………. ;

which satisfies the conditions set out in subparagraph b, i, ii, and iii, of paragraph 7 of article 29 of the France-Canada Tax Convention in order to be exempted from French tax levied by withholding tax dividends.

The undersigned agrees to restore to the French treasury, spontaneously or at the request of the French tax authorities, any amount corresponding to a benefit the organization has unduly received.

Location and date

Signature of an officer authorized by the trustee, the pension corporation, or the corporate trustee

Statement of the tax authorities of the recipient’s receiving State

The undersigned hereby certifies that the information provided by the applicant in this application is, to the best of his/her knowledge, accurate, except the compliance with the conditions set out in subparagraph b, ii an iii of paragraph 7 of article 29 which was not verified.

Location and date

Signature of the person authorized by the Canadian tax authorities

Commentaire(s) renvoyant à ce document :

© Ministère de l'Économie et des Finances

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