5003-EN For use by the APPLICATION FOR A REDUCTION …

1 5003-ENRecipient s nameFor use by theforeign taxauthority 12816*01 APPLICATION FOR A REDUCTION OF WITHHOLDING TAXON ROYALTIESA ttachment to Form 5000I) Description of French payer of royaltiesName ..Registered office or management office ..II) Precise description of the goods or rights giving rise to royalty ) To be completed by the French payer of royalties u Please make sure that you complete Boxes I, II and III on Form 5000 Amount of French withholding taxGross amount due Date paid:Amount due (column 1 x treaty rate)Amount paid Amount reclaimed column 4 column 3 Control (do not writein this space)123456 TOTALSAMOUNT DUE(column 3 column 4)AMOUNT TO BE REPAID(column 4 column 3)IV) Declaration of recipient applying for an exemption under Directive 2003/49/EC I hereby certify that I meet the holding requirements stipulated in Directive 2003/49/EC of 3 June 2003 v and, consequently, Iam applying for an exemption from the withholding tax on royalties collected from French and placeSignature of beneficiary or his/her legal representativeYOU ARE A LEGAL ENTITYIf you are eligible for the exemption under Directive 2003/49/EC ofmake sure the Box VI is completedof 3 June 2003 v5003-ENRecipient s nameTo be kept bythe beneficiary 12816*01 APPLICATION FOR A REDUCTION OF WITHHOLDING TAXON ROYALTIESA ttachment to Form 5000I) Description of French payer of royaltiesName.

2 Registered office or management office ..II) Precise description of the goods or rights giving rise to royalty ) To be completed by the French payer of royalties u Please make sure that you complete Boxes I, II and III on Form 5000 Amount of French withholding taxGross amount due Date paid:Amount due (column 1 x treaty rate)Amount paid Amount reclaimed column 4 column 3 Control (do not writein this space)123456 TOTALSAMOUNT DUE(column 3 column 4)AMOUNT TO BE REPAID(column 4 column 3)IV) Declaration of recipient applying for an exemption under Directive 2003/49/EC I hereby certify that I meet the holding requirements stipulated in Directive 2003/49/EC of 3 June 2003 v and, consequently, Iam applying for an exemption from the withholding tax on royalties collected from French and placeSignature of beneficiary or his/her legal representativeYOU ARE A LEGAL ENTITYIf you are eligible for the exemption under Directive 2003/49/EC ofmake sure the Box VI is completedof 3 June 2003 v5003-ENReport du nom du cr ancierFor use by theFrench taxauthorityDEMANDE DE REDUCTION DE LA RETENUE LA SOURCESUR REDEVANCESA nnexe au formulaire n 5000 12816*01I)

3 D signation du d biteur fran ais des redevancesD nomination ou raison sociale ..Si ge social ou de direction ..II) D signation pr cise des biens ou droits g n rateurs des ) A remplir par le d biteur fran ais des revenus u N oubliez pas de faire compl ter par le cr ancier les cadres I, II et III du formulaire n 5000 Montant de l imp t fran ais la sourceMontant brut dessommes encaisseren Date del encaissementExigibleen Col 1 x taux conventionPay en Dont le d gr vementest demand en col 4 col 3 Contr le (cadrer serv l administration)123456 TOTAUXA PAYERCol 3 col 4A REMBOURSERCol 4 col 3IV) D claration du cr ancier demandant le b n fice de la directive n 2003/49/CE Je d clare satisfaire aux conditions de participation pr vues par la directive n 2003/49/CE du 3 juin 2003 v et demande encons quence l exon ration de retenue la source au titre des redevances de source fran aise per et lieuSignature du cr ancier ou de son repr sentant l galVOUS ETES UNE PERSONNE MORALESi vous pouvez b n ficier de l exon ration pr vue par la directive N oubliez pas de remplir le cadre IVn 2009/49/CE du 3 juin 2003 v