FORM - Income and Profit from Movable Assets (RPPM) - Application for exemption from withholding tax on distributed income paid to foreign undertakings for collective investment in transferable securities (UCITS) and certain alternative investment funds (AIFs) - General Tax Code, art. 119 bis, 2

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

I) Income recipient
Corporate name : Trade name : ISIN code (if available, otherwise another code) : Full address of registered office : Number and date of authorisation of the supervisory authority : Name of sub-fund :
II) Income recipient's management company
Corporate name : Trade name : Full address of registered office :
III) Sworn statement
The undersigned, the income recipient’s representative or management company, hereby certifies : - that the company or investment fund for which the exemption from withholding tax is being applied for is the actual recipient of the distributions - that the company or investment fund for which the exemption from withholding tax is being applied for 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 country or territory (NCCT) 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 that represents the circumstances of the UCI for which exemption from withholding tax is being applied for and provide all the information requested in the fourth column. Otherwise this statement shall be invalidated.

Types of undertaking for collective investment	Criteria required for 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" AIF	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 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 management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of statutory auditor : full contact details, name, address, identification and/or registration number : . . .
	Commitment to compliance with the rules set out in the UCITS Directive
AIF 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 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 management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of 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, surveillance, cooperation, equivalent protection rules for unit-holders (division of risk) on UCITS asset mix requirements	Authorisation number : .
AIF "open to professional investors" and under certain conditions to non-professional investors	Authorisation or registration
	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 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 management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of statutory auditor : full contact details, name, address, identification and/or registration number : . . .
AIF equivalent to closed-end investment company (SICAF) governed by French law	Management company	Identification of 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 depositary : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of statutory auditor : full contact details, name, address, identification and/or registration number : . . .
AIF equivalent to a real estate undertaking for collective investment (OPCI) 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 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 management company : full contact details, name, address, identification and/or registration number : . . .
	Financial statements certified by a statutory auditor	Identification of statutory auditor : full contact details, name, address, identification and/or registration number : . . .
	At least 60 % of assets composed 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)

Commentaire(s) renvoyant à ce document :

FORMULAIRE - RPPM - Demande d'exonération de retenue à la source sur les revenus distribués versés à des organismes de placement collectif de valeurs mobilières (OPCVM) et certains FIA étrangers (CGI, art. 119 bis, 2)

RPPM - Revenus et profits du patrimoine mobilier, gains et profits assimilés - Régime fiscal des revenus distribués par les sociétés françaises à des non-résidents - Exonérations totales ou partielles de retenue à la source sur les revenus distribués versés à certains organismes de placement collectif étrangers (CGI, art. 119 bis, 2)

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