Fillable BENEFICIAL OWNERSHIP AFFIDAVIT with REGISTERED OWNERSHIP

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BENEFICIAL OWNERSHIP AFFIDAVIT with REGISTERED OWNERSHIP

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BENEFICIAL OWNERSHIP AFFIDAVIT with REGISTERED OWNERSHIP
Clearstream Operations Prague s.r.o.
Attn: PTR - Tax Reclaim Services
Futurama Business Park Building B
Sokolovska 662/136b
CZ-18600 Prague 8
Czech Republic
I, the undersigned, _________________________________________________ (name of officer of the trustee/custodian),
being duly sworn and deposed, do hereby state that I am an authorised officer of:
_____________________________________________________________________________ (name of trustee/custodian)
and that _______________________________________________________________________(name of beneficial owner)
was the beneficial owner of _________________ (quantity) shares of:
______________________________________________________________________________ (name of security)
payable on __________ (date) registered in the name of ___________________________________ (registered owner)
and that said shares are the property of ___________________________________________(name of beneficial owner)
and are held as such by ________________________________________________________ (name of trustee/custodian)
and that ________________________________________________________________ (name of trustee/custodian)
has no interest whatsoever in the shares mentioned above except as nominee.
Signed:
__________________________________________________________________ (officer of trustee/custodian)
Date: ______________________
OFFICIAL SEAL OF
NOTARY PUBLIC
(continued on next page)
BENEFICIAL OWNERSHIP AFFIDAVIT with REGISTERED OWNERSHIP (cont)
(continued from previous page)
How to complete the “BENEFICIAL OWNERSHIP AFFIDAVIT with REGISTERED OWNERSHIP
1. Name of officer of the trustee/custodian
The entity to input their name as officer of “Trustee/ Custodian” would be the following:
Officer of the “final Financial institution” (for example, Mr Schmit officer of XX Banking) - if the
beneficial owner is holding the position directly via a Financial institution other than Clearstream.
2. Name of trustee/ Custodian
The name of the entity to “Trustee/ Custodian” would be the following:
The “final Financial institution” (for XX Banking) - if the beneficial owner is holding the position directly
via a Financial institution other than Clearstream.
3. Name of the beneficial owner
This would be the name of the final beneficial owner requesting the reclaim.
4. Name of the registered owner
This would be “Clearstream” being RBC Dexia’s client (Client of the Canadian Payer or Agent who withheld
the tax).
5. Signed by officer of trustee/custodian
The officer to sign, as officer of “Trustee/ Custodian” would be the following:
Officer of the “final Financial institution” - if the beneficial owner is holding the position directly via a
Financial institution other than Clearstream.
This template has been provided by our depository and is provided for information purpose only.
Clearstream Banking makes no guarantees, representations or warranties and accepts no responsibility
or liability as to the accuracy or completeness of the information, and under no circumstances will it be
liable for any loss or damage caused by reliance on any opinion, advice or statement made therein
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BENEFICIAL OWNERSHIP AFFIDAVIT with REGISTERED OWNERSHIP

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Completed 4 April 2022

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