Treaty Statement for Legal Entity Accounts

Under US Internal Revenue Service Section 871(m) and the regulations thereunder, any dividends paid to non-US taxpayers on derivatives of US equities are subject to a withholding tax.

By confirming your information, we can ensure we are giving you the most favorable rate and avoid any additional withholding. You can find out more information about Section 871m in our information sheet, check IRS information or contact your tax advisor.

Please complete the form in its entirety on behalf of the organisation that holds the account (beneficial owner). View the Treaty Summary Definitions to assist you with the completion of this form.

* Name of organisation that is the beneficial owner:

The above named meets all provisions of the applicable treaty that are necessary to claim a reduced rate of withholding, including any limitation on benefits provisions, and derives the income within the meaning of section 894, and the regulations thereunder, as a beneficial owner.

Please complete each section below by ticking boxes where applicable and filling all required information marked with*

I certify that:

*1. The beneficial owner is a resident of
within the meaning of the income tax treaty between the United States and that country and holds the following
Taxpayer Identification Number (TIN)
*2. The beneficial owner derives the item(s) of income for which treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits.
The following are types of limitation on benefits provisions that may be included in an applicable tax treaty. Please select one:

*3. The beneficial owner is claiming treaty benefits for U.S. source dividends or interest from a U.S. trade or business of a foreign corporation and meets qualified resident status.


I declare that the information provided in this form is, to the best of my knowledge and belief, accurate and complete.

I undertake to advise you promptly of any change in circumstance which causes the information contained herein to become incorrect or incomplete and to provide you with an updated declaration as soon as possible.

Please note this Treaty Statement is valid for three years from the date you enter below

*Customer Signature

(Enter full name of individual authorised to sign for beneficial owner)


*Capacity in which acting:

Indicate the capacity in which you are signing the form (e.g. Director, Authorised Signatory). If signing under a power of attorney, please send a certified copy of the power of attorney to

Please make a selection under section 2.
All of the points and declarations must be ticked.
Vn 14 July 2017