Recipient’s name
5002-EN
For use by the
foreign tax
authority
CALCULATION AND REPAYMENT OF
WITHHOLDING TAX ON INTEREST
Attachment to Form 5000
12816*01
I) To be completed by the recipient
II) To be completed by the paying institution
Please make sure that you complete Boxes I, II, III and VII of Form 5000
Please make sure that Box V of Form 5000 has
been completed
Description of income Tax calculation
French payer
Payment
date
Number
of
securities
Unit value or
total interest
paid
Tax due under
the applicable
tax treaty
(column 3 x
column 4 x treaty
rate or col 4 x
treaty rate)
Amount of
French tax paid
(column 3 x column
4 x domestic rate
or col 4 x
domestic rate)
Amount
reclaimed
(Column 5 –
Column 6)
1 2 3 4 5 6 7
TOTALS
AMOUNT DUE
(Column 5 –
Column 6)
AMOUNT TO BE
REPAID (Column 6
– Column 5)
III) Declaration of recipient applying for an exemption
under Directive 2003/49/EC (art.119 quater of the CGI)
I hereby certify that I meet the holding requirements stipulated in Directive 2003/49/EC of 3 June 2003 (art. 119 quater of
the CGI) and, consequently, I am applying for an exemption from the withholding tax on interest collected from French
sources.
…………………………………………………….
Date and place Signature of beneficiary or his/her legal representative
YOU ARE A LEGAL ENTITY
If you are eligible for the exemption under Directive 2003/49/EC of make sure the Box III is completed
3
june 2003 (article 119 quater of
the CGI)
cerfa
@ internet - DGFiP
To validate and print
Re-initialize the form
Recipient’s name
5002-EN
To be kept by
the beneficiary
CALCULATION AND REPAYMENT OF
WITHHOLDING TAX ON INTEREST
Attachment to Form 5000
12816*01
I) To be completed by the recipient
II) To be completed by the paying institution
Please make sure that you complete Boxes I, II, III and VII of Form 5000
Please make sure that Box V of Form 5000 has
been completed
Description of income Tax calculation
French payer
Payment
date
Number
of
securities
Unit value or
total interest
paid
Tax due under
the applicable
tax treaty
(column 3 x
column 4 x treaty
rate or col 4 x
treaty rate)
Amount of
French tax paid
(column 3 x column
4 x domestic rate
or col 4 x
domestic rate)
Amount
reclaimed
(Column 5 –
Column 6)
1 2 3 4 5 6 7
TOTALS
AMOUNT DUE
(Column 5 –
Column 6)
AMOUNT TO BE
REPAID (Column 6
– Column 5)
III) Declaration of recipient applying for an exemption
under Directive 2003/49/EC (art.119 quater of the CGI)
I hereby certify that I meet the holding requirements stipulated in Directive 2003/49/EC of 3 June 2003 (art. 119 quater of
the CGI) and, consequently, I am applying for an exemption from the withholding tax on interest collected from French
sources.
…………………………………………………….
Date and place Signature of beneficiary or his/her legal representative
YOU ARE A LEGAL ENTITY
If you are eligible for the exemption under Directive 2003/49/EC of make sure the Box III is completed
3
june 2003 (article 119 quater of
the CGI)
cerfa
@ internet - DGFiP
Report du nom du créancier
5002-EN
For use by the
French tax
authority
LIQUIDATION ET REMBOURSEMENT
DU PRÉLÈVEMENT À LA SOURCE SUR INTÉRÊTS
Annexe au formulaire n°5000
12816*01
I) A remplir par le créancier
II) 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
Désignation du revenu Liquidation de l’impôt
Débiteur français
Date de
mise en
paiement
Nombre
de titres
Valeur
unitaire ou
total des
intérêts
versés
en €
Montant de
l’impôt exigible
en application
de la convention
en €
(col 3 x col 4 x
taux convention
ou col 4 x taux
convention)
Montant de
l’impôt français
payé
en €
(col 3 x col 4 x
taux interne ou
col 4 x taux
interne)
Montant du
dégrèvement
demandé
en €
(col 5 – col 6)
1 2 3 4 5 6 7
TOTAUX
A PAYER
Col 5 – Col 6
A REMBOURSER
Col 6 – col 5
III) Déclaration du créancier demandant le bénéfice de
la directive n° 2003/49/CE (art. 119 quater du CGI)
Je déclare satisfaire aux conditions de participation prévues par la directive 2003/49/CE du 3 juin 2003 demande en
conséquence l’exonération de retenue à la source au titre des intérêts de source française perçus .
………………………………………………...
Date et lieu Signature du créancier ou de son représentant légal
VOUS ÊTES UNE PERSONNE MORALE
Si vous pouvez bénéficier de l’exonération prévue par la directive N’oubliez pas de compléter le cadre III
n° 2003/49/CE du 3 juin 2003 (art. 119 quater du CGI)
cerfa
@ internet - DGFiP
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