Form 5000-EN: Affidavit of Residence

Write the name of the country in the box, and the Number of attachments.

Under I) Types of income, check Dividends, Interest or Royalties. Dividends: check Normal procedure (Attach Form 5001) or Simplified procedure (File this certificate of residence only). Interest: Attach Form 5002. Royalties: Attach Form 5003.

Under II) Beneficiary, enter the Surname and first name, or company name, the Occupation / Legal form, the Full home address or registered office and the E-mail.

For United States residents.

Investment companies and funds please complete box VII as well.

Under III) Beneficiary's declaration, declare that you are beneficially entitled to the income for which the treaty benefits are being claimed.

Enter where the beneficiary is a resident (or, in the case of pension fund or an investment company, is established).

Write the name of the country of residence under whose laws you are subject to the tax, including with respect to French-source dividends. Notwithstanding, this condition is not required under the terms of certain tax treaties with France.

You declare that you do not have any establishment or permanent base that this income is attached to in France and that this income has been or will be reported to the tax authorities in your country of residence.

Enter the Date and place and the Signature of beneficiary or his/her legal representative.

Under IV) Declaration of the foreign tax authority, the tax authority certifies that to the best of its knowledge the information provided by the applicant is correct.

The tax authority certifies that, for the purposes of the abovementioned tax treaty, the beneficiary is a resident (or, in the case of pension fund or an investment company, is established).

The tax authority certifies that the beneficiary of the income is subject to taxation by the authority under the tax identification number (where applicable).

The Date and place and the Signature and seal are the tax authority's.

Under V) Declaration of the paying institution, enter the Name, the Address and the SIREN number.

The paying institution declares that it has paid the beneficiary, in respect of ..., the income referred to in this application, net of the withholding tax at the rate provided for in French domestic law.

The paying institution enters the Date and place and its Signature and Seal.

Under VI) Declaration of the financial institution (For beneficiaries who are United States residents only), the institution enters its Name and the Address.

The abovenamed institution certifies that, to the best of its knowledge, the applicant is a resident of the United States and that the information provided on this form is correct. Enter the institution's Date and place and Signature and seal.

Under VII) Investment company or fund, enter the Financial year, the Number of unit holders or shareholders in fund and the Percentage of unit holders or shareholders who are residents.

In the case of German funds, if the French authorities have issued an authorisation, enter the authorisation date and number.

Under VIII) In case of direct refund by the tax authority, enter where the repayment should be sent (bank, post office, account) and send an IBAN/SWIFT.