For use by the CERTIFICATE OF RESIDENCE

1 5000-ENFor use by theforeign taxauthorityCERTIFICATE OF RESIDENCE 12816*01 Application for implementation of the tax treaty between France andNumber ofattachmentsPlease write the name of the country in this boxI) Types of income n Dividends o Normal procedure Simplified procedureAttach Form 5001 File this CERTIFICATE ofresidence only Interest o Royalties oAttach Form 5002 Attach Form 5003II) BeneficiarySurname and first name , orcompany nameOccupationFull home addressor registered United States residentsSee note ) Beneficiary s declarationInvestment companies and funds please complete box VII as well sI hereby declare that:- I am beneficially entitled to the income for which the treaty benefits are being claimed;- For the purposes of the abovementioned tax treaty, the beneficiary is a resident of (or in the case of pension fund r oran investment company s, is established in).

2 Q ;- I do not have any establishment or permanent base that this income is attached to in France;- This income has been or will be reported to the tax authorities in my country of and placeSignature of beneficiary or his/her legal representativeIV) Declaration of the foreign tax authorityThe tax authority of ..q hereby certifies that to the best of its knowledge:- The information provided by the applicant is correct;- For the purposes of the abovementioned tax treaty, the beneficiary is a resident of (or in the case of pension fund r oran investment company s, is established in).

3 Q ;- The beneficiary of the income is subject to taxation by the authority under the tax identification number ..(where applicable)..Date and placeSignature and sealV) Declaration of the paying institutionNameAddressSIREN hereby declare that we have paid the beneficiary the income referred to in this application, net of the withholding tax atthe rate provided for in French domestic and placeSealVI) Declaration of the US financial institution t(For beneficiaries who are United States residents only) abovenamed institution hereby certifies that, to the best of its knowledge, the applicant is a resident of the United States andthat the information provided on this form is and placeSealVII) Investment company or fund s- Financial year ; s- In the case of German funds, if the French authoritieshave issued an authorisation: authorisation date and number:authorisation number.

4 Date ..- Number of unit holders or shareholders in fund:.. - Percentage of unit holders or shareholders who areresidents of: .. q : .. %VIII) In case of direct refund by the tax authorityWhere should the repayment be sent (bank, post office, account) ?..5000-ENTo be kept bythe beneficiaryCERTIFICATE OF RESIDENCE 12816*01 Application for implementation of the tax treaty between France andNumber ofattachmentsPlease write the name of the country in this boxI) Types of income n Dividends o Normal procedure Simplified procedureAttach Form 5001 File this CERTIFICATE ofresidence only Interest o Royalties oAttach Form 5002 Attach Form 5003II) BeneficiarySurname and first name , orcompany nameOccupationFull home addressor registered United States residentsSee note )

5 Beneficiary s declarationInvestment companies and funds please complete box VII as well sI hereby declare that:- I am beneficially entitled to the income for which the treaty benefits are being claimed;- For the purposes of the abovementioned tax treaty, the beneficiary is a resident of (or in the case of pension fund r oran investment company s, is established in) .. q ;- I do not have any establishment or permanent base that this income is attached to in France;- This income has been or will be reported to the tax authorities in my country of and placeSignature of beneficiary or his/her legal representativeIV) Declaration of the foreign tax authorityThe tax authority of.

6 Q hereby certifies that to the best of its knowledge:- The information provided by the applicant is correct;- For the purposes of the abovementioned tax treaty, the beneficiary is a resident of (or in the case of pension fund r oran investment company s, is established in) .. q ;- The beneficiary of the income is subject to taxation by the authority under the tax identification number ..(where applicable)..Date and placeSignature and sealV) Declaration of the paying institutionNameAddressSIREN hereby declare that we have paid the beneficiary the income referred to in this application, net of the withholding tax atthe rate provided for in French domestic and placeSealVI) Declaration of the US financial institution t(For beneficiaries who are United States residents only)

7 Abovenamed institution hereby certifies that, to the best of its knowledge, the applicant is a resident of the United States andthat the information provided on this form is and placeSealVII) Investment company or fund s- Financial year ; s- In the case of German funds, if the French authoritieshave issued an authorisation: authorisation date and number:authorisation number .. date ..- Number of unit holders or shareholders in fund:.. - Percentage of unit holders or shareholders who areresidents of: .. q : .. %VIII) In case of direct refund by the tax authorityWhere should the repayment be sent (bank, post office, account) ?

8 5000-ENFor use by theFrench taxauthorityATTESTATION DE RESIDENCE 12816*01 Demande d application de la convention fiscale entre la France etNombre d annexesInscrire dans cette case le nom de l Etat contractantI) Nature des revenus n Dividendes o Proc dure normale Proc dure simplifi eJoindre un formulaireannexe n 5001 File this CERTIFICATE ofresidence only Int r ts o Redevances oJoindre un formulaireannexe n 5002 Joindre un formulaireannexe n 5003II) D signation du b n ficiaire des revenusNom et pr nom ou raison socialeProfessionAdresse compl te du domicileou du si ge les r sidents des Etats-Uniscf.

9 Notice ) D claration du b n ficiaire des revenusFonds et soci t s d investissement : compl ter aussi le cadre VII sLe soussign certifie :- tre le b n ficiaire effectif des revenus pour lesquels le b n fice de la convention est demand ;- avoir, au sens de la convention fiscale susvis e, la qualit de r sident de (ou s agissant d un fonds de pension r ou d unfonds ou d une soci t d investissement s tre tabli ) .. q ;- ne pas poss der en France d tablissement ou de base fixe auxquels se rattachent les revenus ;- que ces revenus ont t ou seront d clar s l administration des imp ts de l Etat de r et lieuSignature du b n ficiaire ou de son repr sentant l galIV) D claration de l administration trang reL administration fiscale de.

10 Q certifie qu sa connaissance :- les indications port es par le d clarant sur la pr sente demande sont exactes ;- au sens de la convention fiscale susvis e le b n ficiaire a bien la qualit de r sident de (ou s agissant d un fonds depension r ou d un fonds ou d une soci t d investissement s tre tabli ) .. q ;- le b n ficiaire des revenus rel ve de son ressort sous le num ro fiscal ..(si un tel num ro existe)..Date et lieuSignature et tamponV) D claration de l tablissement payeurNom / D nominationAdresseNum ro certifions avoir pay au b n ficiaire les revenus compris dans la pr sente demande pour leur montant net c est dired duction faite de l imp t la source au taux pr vu par le droit interne fran et lieuCachetVI) D claration de l tablissement financier am ricain t(pour les seuls b n ficiaires r sidents des Etats-Unis)