FORM - Income and Profit from Movable Assets (RPPM) - Application for exemption from withholding tax on distributed income paid to foreign undertakings for collective investment (UCIs) that are not listed as one of the types of collective investment vehicle (CIV) in BOI-FORM-000037 and BOI-FORM-000086 (General Tax Code, Art. 119 bis, 2)

This form should be presented to the payer institution to obtain an exemption from withholding tax or to the tax authorities to be granted a ruling or repayment of the withholding tax (BOI-RPPM-RCM-30-30-20-70).

This form is available in French in BOI-FORM-000089.

I) Identification of the income beneficiary
Name : Corporate name : ISIN code (if available, otherwise another code) : Full address of registered office : Authorisation or registration number with the supervisory authority :
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 (1) - 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. (1) When the representative or management company of the income beneficiary intends to rely on a ruling or decision to repay withholding tax in order to be granted an exemption from this tax in favour of the beneficiary, they certify, by signing this statement, that the characteristics set out in I-B-1 § 92 to 99 of BOI-RPPM-RCM-30-30-20-70 of the company or investment fund for which withholding tax exemption is being applied for have not, since the decision on the ruling or repayment by the tax authorities, been subject to any change that compromises compliance with the exemption conditions stipulated in Article 119 bis(2) of the General Tax Code.
Date and place	Signature and stamp of the representative or management company

Complete each section below and, when the investment company or fund is unable to rely on a ruling or decision to repay withholding tax from the tax authorities, provide the requested information and documents to support the statement of compliance with each criterion.

The list of information and documents to provide, set out in the fourth column, is not exhaustive. The representative or management company of the income beneficiary may provide any additional document that they deem relevant to justify the exemption being applied for.

When the investment company or fund intends to rely on a ruling or decision to repay withholding tax from the tax authorities, under the conditions stipulated in II-A-1-c § 152 of BOI-RPPM-RCM-30-30-20-70, the decision must be attached to this form.

Should the application be incomplete, the statement that the income beneficiary complies with the comparability criteria required to apply the exemption shall not be deemed valid.

In all cases, the tax authorities may ask the investment company or fund for any additional document or information that it considers necessary to assess the situation of said company or fund with respect to the conditions provided for in Article 119 bis(2) of the General Tax Code.

Types of CIV	Characteristics required to benefit from the exemption	Information and documents to provide
UCI not listed as one of the types of CIV referred to in BOI‑FORM-000037 and BOI‑FORM-000086	Existence of an authorisation or a registration with a supervisory authority (administrative, banking or financial)	Authorisation number and authorisation or registration number and registration Identification of the approving authority
	No control of the fund by the shareholders	Fund’s rules
	Existence of a reference document for investors prior to any subscription tailored to the capacity of targeted investors (professional and/or non-professional investors)	Reference documents
	Existence of a management company approved by a supervisory authority, acting on behalf of the fund or, otherwise, approved staff and technical resources at fund level to manage it	Identification of the management company: full contact details, name, address, identification and/or registration number Or identification of staff approved to manage the fund (name, address, approval number) and description of the technical resources rolled out References to the regulations binding on the company and management team
	Existence of a depositary that is distinct from the fund manager subject to prudential oversight and tasked with controlling, under its own responsibility, the fund manager or, otherwise, various service providers distinct from the manager carrying out, under their own responsibility, the duties assigned to a depositary	Identification of the depositary : full contact details, name, address, identification and/or registration number Or identification of various service providers carrying out the duties assigned to a depositary : full contact details, name, address, identification and/or registration number, and description of the respective duties Legal provisions and/or contractual stipulations providing for the principle of the depositary’s liability in order to ensure protection of investors funds Contract with the depositary or service providers
	Implementation of an investment and risk-distribution policy	References of the legal, regulatory or contractual requirements imposing the distribution of risks Prospectus, similar document or contractual terms and conditions for investment including risk diversification methods comparable to those laid down by French and European legislation
	Financial statements certified by an independent statutory auditor	Identification of the statutory auditor: full contact details, name, address, identification and/or registration number

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