N° 5001 EN Pdf
User Manual: 5001
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INDIVIDUALS AND LEGAL ENTITIES: o
If the dividends have not been
p
aid
y
et
,
y
ou ma
y
be eli
g
ible for the sim
p
lified
p
rocedure.
Recipient’s name 5001-EN
For use by the
foreign tax
authority
CALCULATION OF WITHHOLDING TAX ON DIVIDENDS
Attachment to Form 5000 12816*01
I) Declaration of recipient applying for the
parent company system o
I hereby certify that I meet the requirements stipulated:
□ in Article ….... of the tax treaty between France and………………………………………………………………………..… q
and I therefore request an exemption from withholding tax / a reduction in the rate of withholding tax to …….…… per cent.
□ Directive 90/435/EEC of 23 July 1990 (article 119ter of the French tax code). Accordingly, I certify that the recipient
company:
a) has its effective place of management in a Member State of the European Union and is not considered, under the terms of a
double tax agreement with a third country, to be resident for tax purposes outside the Europe Union;
b) takes one of the forms listed in the order issued on ../…/…. by the Minister of the Economy, Finance and Industry, pursuant
to the Annex to Directive 90-435 of the Council of 23 July 1990, amended by Directive 2003/123/EC of the Council of 22
December 2003;
c) has held directly, for an uninterrupted period of two years or more, at least 20 per cent of the capital of the entity
distributing the dividends. The aforementioned holding shall be reduced to 15 per cent for dividends distributed between
1 January 2007 and 31 December 2008 and to 10 per cent for dividends distributed from 1 January 2009 onwards (1); or
d) has made an undertaking to maintain its holding for an uninterrupted period of two years or more and to appoint a
representative who shall be responsible for paying withholding tax and, where such is the case, the penalties referred to in Article
1765bis of the French tax code. (That undertaking must reach the Centre des impôts des non-résidents (non-resident tax centre)
10, rue du Centre, TSA 10 010, 93 465 NOISY LE GRAND CEDEX, FRANCE, and the paying institution in France before the first
dividend payment date following book-entry registration of the shares of the distributing company.) (1)
e) is subject to corporate income tax in the Member State where it has its effective place of management, without the
possibility of an option or of being exempt.
I also certify that, to the best of my knowledge, this entity is not controlled directly or indirectly by one or more residents of
countries that are not European Union members (1); or
I also certify that, to the best of my knowledge, this entity is controlled directly or indirectly by one or more residents of
countries that are not European Union members but that this chain of holdings does not seek, as its main purpose or one of its
main purposes, to take advantage of the withholding tax exemption provided for in Article 119bis (2) of the French tax code(1).
If the company transfers its effective place of management to another European Union Member State or if there is a change in
its legal or tax situation, I hereby undertake to send a new form, based on this form, to the paying institution in France, or, where
such is the case, to the subsidiary resident in France that pays the dividend directly, no later than the first dividend date following
such transfer or change.
(1) Cross out the statement that does not apply
………………………………………………...
Date and place Signature of beneficiary or his/her legal representative
@ internet - DGI
II) To be completed by the recipient uIII) To be completed by the paying institution
Please make sure that the Boxes I, II, III, and VII on Form 5000 have been completed Please make sure that Box V of Form 5000 has been completed
Parent company system
French company paying the dividends(1) Dividend
payment
date
Number of
shares
Holding % Date on which
this holding %
was reached
Dividend par
share (2)
€
Total amount
€
(column 3 x
column 6)
Total
withholding
tax under
domestic
legislation
€
(column 7 x
25%)
Withholding
tax due under
the applicable
tax treaty
€
(column 7 x
treaty rate)
Withholding
tax deducted
€
Amount
reclaimed
€
(column 10 –
column 9)
1234567891011
TOTAL
(1) Exact name and address of the company paying dividends, except for listed companies. (2) Gross amount before withholding tax
@ internet - DGI
INDIVIDUALS AND LEGAL ENTITIES: o
If the dividends have not been
p
aid
y
et
,
y
ou ma
y
be eli
g
ible for the sim
p
lified
p
rocedure.
Recipient’s name 5001-EN
To be kept by
the recipient
CALCULATION OF WITHHOLDING TAX ON DIVIDENDS
Attachment to Form 5000 12816*01
I) Declaration of recipient applying for the
parent company system o
I hereby certify that I meet the requirements stipulated:
□ in Article ….... of the tax treaty between France and………………………………………………………………………..… q
and I therefore request an exemption from withholding tax / a reduction in the rate of withholding tax to …….…… per cent.
□ Directive 90/435/EEC of 23 July 1990 (article 119ter of the French tax code). Accordingly, I certify that the recipient
company:
a) has its effective place of management in a Member State of the European Union and is not considered, under the terms of a
double tax agreement with a third country, to be resident for tax purposes outside the Europe Union;
b) takes one of the forms listed in the order issued on ../…/…. by the Minister of the Economy, Finance and Industry, pursuant
to the Annex to Directive 90-435 of the Council of 23 July 1990, amended by Directive 2003/123/EC of the Council of 22
December 2003;
c) has held directly, for an uninterrupted period of two years or more, at least 20 per cent of the capital of the entity
distributing the dividends. The aforementioned holding shall be reduced to 15 per cent for dividends distributed between
1 January 2007 and 31 December 2008 and to 10 per cent for dividends distributed from 1 January 2009 onwards (1); or
d) has made an undertaking to maintain its holding for an uninterrupted period of two years or more and to appoint a
representative who shall be responsible for paying withholding tax and, where such is the case, the penalties referred to in Article
1765bis of the French tax code. (That undertaking must reach the Centre des impôts des non-résidents (non-resident tax centre)
10, rue du Centre, TSA 10 010, 93 465 NOISY LE GRAND CEDEX, FRANCE, and the paying institution in France before the first
dividend payment date following book-entry registration of the shares of the distributing company.) (1)
e) is subject to corporate income tax in the Member State where it has its effective place of management, without the
possibility of an option or of being exempt.
I also certify that, to the best of my knowledge, this entity is not controlled directly or indirectly by one or more residents of
countries that are not European Union members (1); or
I also certify that, to the best of my knowledge, this entity is controlled directly or indirectly by one or more residents of
countries that are not European Union members but that this chain of holdings does not seek, as its main purpose or one of its
main purposes, to take advantage of the withholding tax exemption provided for in Article 119bis (2) of the French tax code(1).
If the company transfers its effective place of management to another European Union Member State or if there is a change in
its legal or tax situation, I hereby undertake to send a new form, based on this form, to the paying institution in France, or, where
such is the case, to the subsidiary resident in France that pays the dividend directly, no later than the first dividend date following
such transfer or change.
(1) Cross out the statement that does not apply
………………………………………………...
Date and place Signature of beneficiary or his/her legal representative
@ internet - DGI
II) To be completed by the recipient uIII) To be completed by the paying institution
Please make sure that the Boxes I, II, III, and VII on Form 5000 have been completed Please make sure that Box V of Form 5000 has been completed
Parent company system
French company paying the dividends(1) Dividend
payment
date
Number of
shares
Holding % Date on which
this holding %
was reached
Dividend par
share (2)
€
Total amount
€
(column 3 x
column 6)
Total
withholding
tax under
domestic
legislation
€
(column 7 x
25%)
Withholding
tax due under
the applicable
tax treaty
€
(column 7 x
treaty rate)
Withholding
tax deducted
€
Amount
reclaimed
€
(column 10 –
column 9)
1234567891011
TOTAL
(1) Exact name and address of the company paying dividends, except for listed companies. (2) Gross amount before withholding tax
@ internet - DGI
PERSONNES PHYSIQUES OU MORALES : o
Si les dividendes n’ont
p
as encore été mis en
p
aiement
,
vous
p
ouvez
p
eut-être bénéficier de la
p
rocédure sim
p
lifiée
Report du nom du créancier 5001-EN
For use by the
French tax
authority
LIQUIDATION DE LA RETENUE À LA SOURCE SUR DIVIDENDES
Annexe au formulaire 5000 12816*01
I) Déclaration du créancier demandant le
bénéfice du régime des sociétés mères o
Je déclare satisfaire aux conditions de participation prévues :
□ à l’article ….... de la convention fiscale conclue entre la France et ………………………………………………………..… q
et demande en conséquence l’exonération de la retenue à la source / la réduction à …….…… % du taux de retenue à la source.
□ aux conditions de la Directive 90/435/CEE du 23.07.1990 (article 119 ter du CGI). Dans ce cas, j’atteste que la société
répond aux conditions suivantes :
a) avoir son siège de direction effective dans un Etat membre de l'Union européenne et n'être pas considérée, aux termes d'une
convention préventive de double imposition conclue avec un Etat tiers, comme ayant sa résidence fiscale hors de l'Union ;
b) revêtir l'une des formes énumérées sur une liste établie par l'arrêté du ../…/…. du ministre de l'économie, des finances et
l’industrie conformément à l'annexe de la directive n° 90-435 du Conseil, du 23 juillet 1990, modifiée par la directive
2003/123/CE du Conseil, du 22 décembre 2003 ;
c) détenir directement, de façon ininterrompue depuis deux ans ou plus, 20 % au moins du capital de la personne morale qui
distribue les dividendes. Le taux de participation susvisé est ramené à 15 % pour les dividendes distribués entre le 1er janvier
2007 et le 31 décembre 2008 et à 10 % pour les dividendes distribués à compter du 1er janvier 2009 (1) ; ou
d) avoir pris l'engagement de conserver cette participation de façon ininterrompue pendant un délai de deux ans au moins et
désigner un représentant qui est responsable du paiement de la retenue à la source ainsi que, le cas échéant, des pénalités
mentionnées à l'article 1765 bis du code général des impôts (cet engagement devra parvenir au centre des impôts des non-
résidents – 10, rue du Centre, TSA 10 010, 93 465 NOISY LE GRAND CEDEX – et à l'établissement payeur en France avant la date
de la première mise en paiement des dividendes qui suit la date d'inscription en compte des titres de la société distributrice). (1)
e) être passible, dans l'Etat membre où elle a son siège de direction effective, de l'impôt sur les sociétés de cet Etat, sans
possibilité d'option et sans en être exonérée.
J'atteste également qu'à ma connaissance cette personne morale n'est pas contrôlée directement ou indirectement par un ou
plusieurs résidents d'Etats qui ne sont pas membres de l'Union européenne (1) ; ou
J'atteste également qu'à ma connaissance cette personne morale est contrôlée directement ou indirectement par un ou plusieurs
résidents d'Etats qui ne sont pas membres de l'Union européenne, mais que la chaîne de participations n'a pas comme objet
principal ou comme un de ses objets principaux de tirer avantage de l’exonération de la retenue à la source prévue au 2 de
l'article 119 bis du code général des impôts (1).
En cas de transfert du siège de direction effective de la société dans un autre Etat de l'Union européenne ou de modification de sa
situation juridique ou fiscale, je m'engage à transmettre à l'établissement payeur en France des dividendes, ou le cas échéant à ma
filiale résidente de France si celle-ci assure directement le paiement des dividendes, au plus tard lors de la première distribution
de dividendes suivant ce transfert ou cette modification, un nouveau document établi sur le même modèle que la présente
attestation.
(1) Rayer la mention inutile.
………………………………………………...
Date et lieu Signature du créancier ou de son représentant légal
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II) A remplir par le créancier vIII) A remplir par l’établissement payeur
N’oubliez pas de compléter les cadres I, II, III et VII du formulaire n°5000 N’oubliez pas de compléter le cadre V du formulaire n°5000
Régime des sociétés mères
Société française débitrice des dividendes(1)
Date de
mise en
paiement
des
dividendes
Nombre de
titres Pourcentage de
participation
Date à laquelle
le seuil a été
atteint
Valeur unitaire
du coupon (2)
en €
Montant
total
en €
col 3 x col 6
Retenue à la
source totale
en vertu de la
législation
interne
en €
(col 7 x 25 %)
Retenue à la
source
exigible en
application de
la convention
applicable
en €
(col 7 x taux
conventionnel)
Retenue à la
source
effectivement
prélevée
en €
Montant du
dégrèvement
demandé
en €
(col 10 – col 9)
1234567891011
TOTAL
(1) Coordonnées précises de la société distributrice, sauf sociétés cotées en bourse (2) Montant brut avant déduction de l’impôt à la source
@ internet - DGI
