Statement to be completed by Canadian mutual funds
in securities contemplated in Article 29,paragraph 7, subparagraph (a)
For the exemption/ the reduction(1) of French tax on the fraction of French dividends/interest(1) paid to
these organizations which flow through to residents of Canada and which is taxable in the hands of
those residents, in accordance with the France-Canada Tax Convention of May 2, 1975, as amended
by the Protocol dated November 30, 1995.
The undersigned (name and address)…………………………..…...……………………...hereby certifies
that the organization …………………………………………………………………………….(name and
address) constituted in Canada on (date) ……………………………………………., established in
Canada and is:
(a) a mutual fund trust whose account number is ……………..; or
(b) a pooled fund trust whose account number is………………; or
(c) a unit trust whose account number is………………………..;
which satisfies the conditions set out in subparagraph (a) of paragraph 7 of Article 29 of the France-
Canada Tax Convention in order to be exempted/to have reduction(1) from French tax levied by
withholding tax dividends/interest(1),
and certifies that at the end of the accounting period opening……………(date) and closing
…………..(date), the percentage of the rights held by residents of Canada in accordance with
subparagraph (a) of paragraph 1 of Article 4 of the Convention was :…………%
The undersigned agrees to restore to the French treasury, spontaneously or at the request of the
French tax authorities, any amount corresponding to a benefit the organization has unduly received.
Location and date Signature of the recipient or his representative
Statement of the tax authorities of the recipient’s State of Residence
The undersigned hereby certifies that the information provided by the applicant in this application is, to
the best of his/her knowledge, accurate and that the organization is not subject to tax in accordance
to the Convention, except for the percentage of the rights held by residents of Canada which was not
verified.
Location and date Signature of the person authorized by the Canadian
tax authorities
(1) Strike out the inapplicable statement.