ࡱ> `dbjbj55___7E'? $ 6<6<6<P<,< `=="===HHH```````$ah/d6@`Q H/FHHH@`==k`gOgOgOH.= =`gOH`gOgOJRZ\0  2]== R݀6<JF\B^]`0`\BeeNee2]ee 2],HHgOHHHHH@`@` O^HHH`HHHH D/6< 6<  CERTIFICADO PARA ISENO OU DISPENSA DE reteno na fonte sobre rendimentos de valores mobilirios representativos de dvida (N.1 DO ART. 17. DO regime especial de tributao APROVADO PELO DECRETO-LEI N. 193/2005, DE 7 DE NOVEMBRO) O Participante abaixo assinado declara, por este meio, que detm valores mobilirios representativos de dvida abrangidos pelo regime especial de tributao aprovado pelo Decreto-Lei n. 193/2005, de 7 de Novembro (os Valores Mobilirios), na seguinte conta de valores mobilirios com o nmero ..................................................... (a Conta) junto da................................................................................ ......................................................................................................... (nome e morada completa da entidade gestora do sistema de liquidao internacional). Estes Valores Mobilirios sero detidos na qualidade de beneficirio efectivo ou de intermedirio, em nome de um ou mais beneficirios efectivos, incluindo ns prprios se tal for aplicvel, todos beneficiando de iseno ou dispensa de reteno na fonte em conformidade com a legislao portuguesa. 1. Identificao do Participante: Nome: ........................................................................................................................................................... Domiclio fiscal (Morada completa): ........................................................................................................... ....................................................................................................................................................................... Nmero de Identificao Fiscal: .................................................................................................................. 2. Certificamos, por este meio, que a partir da presente data e at ao termo do perodo de validade deste certificado: ( Somos o Beneficirio Efectivo dos seguintes Valores Mobilirios: Cdigo ISIN do Valor MobilirioDescrio do Valor MobilirioPosio Nominal e mais declaramos que no estamos sujeitos a reteno na fonte, em conformidade com a legislao aplicvel, abaixo indicada: Regime Especial de Tributao aprovado pelo Decreto-Lei n. 193/2005, de 7 de Novembro Art 97 do CIRC (Cdigo do Imposto sobre o Rendimento de Pessoas Colectivas) Dispensa de reteno na fonte................................................................................................... B. ( Actuamos como intermedirios dos seguintes Valores Mobilirios: Cdigo ISIN do Valor MobilirioDescrio do Valor MobilirioPosio Nominal os quais so detidos em nome de: Nome: ........................................................................................................................................................... Domiclio fiscal (Morada completa): ........................................................................................................... ....................................................................................................................................................................... Nmero de Identificao Fiscal: ................................................................................................................... e juntamos em anexo uma declarao de titularidade, que inclui a justificao da iseno ou dispensa de reteno de IRS ou de IRC. 3. Comprometemo-nos, por este meio, a fornecer ............................................................................ (nome da entidade gestora do sistema de liquidao internacional) um documento comprovativo da iseno ou dispensa de reteno de IRS ou de IRC, referida na declarao de titularidade em anexo, sempre que o beneficirio efectivo no seja banco central, instituio de direito pblico, organismo internacional, instituio de crdito, sociedade financeira, fundo de penses e empresa de seguros, domiciliada em qualquer pas da OCDE ou em pas com o qual Portugal tenha celebrado conveno para evitar a dupla tributao internacional, em nome do qual detemos valores mobilirios representativos de dvida portuguesa na Conta. 4. Comprometemo-nos, por este meio, a notificar prontamente a ..................................................... .................................................. (nome da entidade gestora do sistema de liquidao internacional) caso alguma das informaes contidas neste certificado venha a tornar-se incorrecta ou incompleta. 5. Temos conhecimento de que a certificao exigida pela legislao portuguesa e autorizamos irrevogavelmente a ............................................................................ (nome da entidade gestora do sistema de liquidao internacional) e respectivo Depositrio a receber e remeter este certificado ou fotocpia, bem como quaisquer anexos e quaisquer informaes relacionadas, s autoridades portuguesas, incluindo as autoridades fiscais. 6. O presente Certificado vlido por um perodo de doze meses a contar da data da assinatura. Local:________________________________ Data:_________________________________ _____________________________________ ______________________________________ Signatrio Autorizado Nome ______________________________________ Ttulo / Cargo _______________________________________ _____________________________________ Signatrio Autorizado Nome _____________________________________ Ttulo / Cargo ANEXO DECLARAO DE TITULARIDADE O beneficirio abaixo assinado: Nome: ........................................................................................................................................ Morada: ..................................................................................................................................... Nmero de identificao fiscal: ................................................................................................ Detentor atravs do seguinte intermedirio financeiro: Nome do intermedirio financeiro: .......................................................................................... .......................................................................................................................................................... Nmero de conta: ...................................................................................................................... Dos seguintes valores mobilirios: Cdigo ISIN:.............................................................................................................................. Designao do valor mobilirio: ............................................................................................... Data do pagamento do rendimento: .......................................................................................... Posio: ..................................................................................................................................... Declara, por este meio, que o beneficirio efectivo dos valores mobilirios e detentor da posio acima mencionada na data de pagamento do rendimento, em ____/___/______; e Declara que no se encontra sujeito a reteno na fonte nos termos da legislao a seguir indicada (assinalar a aplicvel): Regime Especial de Tributao aprovado pelo Decreto-Lei n. 193/2005, de 7 de Novembro Art 97 do CIRC (Cdigo do Imposto sobre o Rendimento de Pessoas Colectivas) Dispensa de reteno na fonte............................................................................................... Art 9 do CIRC Estado, Regies Autnomas, autarquias locais, suas associaes de direito pblico e federaes e instituies de segurana social ........................................................... Art 10 do CIRC Pessoas colectivas de utilidade pblica e de solidariedade social; iseno reconhecida por Despacho Ministerial n. ............. , publicado em Dirio da Repblica ......... Art 16 do EBF (Estatuto dos Benefcios Fiscais) Fundos de penses e equiparveis .......... Art 21 do EBF FPR, FPE, FPR/E ........................................................................................ Art 23 do EBF Fundos de capital de risco .................................................................. Art 26 do EBF Fundos de poupana em aces (FPA) .................................................... Outra legislao (indicar qual) .................................................................................................. O presente documento destina-se a ser apresentado s autoridades fiscais portuguesas, quando solicitado, de acordo com o previsto no Art. 17 do Regime Especial de Tributao aprovado pelo Decreto-Lei n. 193/2005, de 7 de Novembro. Assinatura autorizada: Nome:...................................................................................................... Funo:.................................................................................................... Assinatura:............................................................................................... certificate for exemption from portuguese witholding tax on income from DEBT SECURITIES (PARAGRAPH 1 OF ARTICLE 17 OF the special TAX regime approved by THE DECREE-LAW nr. 193/2005, 7 OF NOVEMBER ) The undersigned Participant hereby declares that he holds debt securities covered by the special tax regime approved by the Decree-Law nr. 193/2005, 7 of November (the Securities), in the following securities account number .. (the Account) with ................................. .................................................................................... (name and complete address of the international clearing system managing entity). We will hold these Securities in our capacity of beneficial owner or in our capacity of intermediary, holding Securities on behalf of one or more beneficial owners, including ourselves, if applicable, all of whom are eligible for exemption at source from Portuguese withholding tax according to Portuguese legislation. 1. We are: Name: ........................................................................................................................................................... Residence for tax purposes (full address): ................................................................................................... Tax ID Number: ........................................................................................................................................... 2. We hereby certify that, from the date hereof until the expiry date of this certificate: A. % We are the Beneficial Owner of the following Securities: Security ISIN or Common CodeSecurity descriptionNominal position and we hereby declare that we are not liable to Portuguese withholding tax, in accordance with the applicable legislation, indicated hereafter: Special Tax Regime approved by the Decree-Law no. 193/2005, 7 of November ...................... Art. 97 of CIRC (Corporate Income Tax Code) Exemption from withholding tax ................... B. % We are intermediaries of the following Securities: Security ISIN or Common CodeSecurity descriptionNominal position which are held on behalf of: Name: ........................................................................................................................................................... Residence for tax purposes (full address): ................................................................................................... TaxID Number: ............................................................................................................................................ and we attach a statement of beneficial ownership, which includes the justification for the exemption of personal or corporate income withholding tax. 3. We hereby undertake to provide the .. (name of the international clearing system managing entity) with a document proving the exemption of personal or corporate income withholding tax referred in the attached statement of beneficial ownership, whenever the beneficial owner is not a central bank, public institution, international body, credit institution, financing company, pensions fund and insurance company resident in any OECD country or in a country with which Portugal has concluded a Convention for the Avoidance of International Double Taxation, on behalf of which we hold Portuguese debt securities in the Account. 4. We hereby undertake to notify the ............................................................... (name of the international clearing system managing entity) promptly in the event that any information contained in this certificate becomes untrue or incomplete. 5. We acknowledge that certification is required in connection with Portuguese law and we irrevocably authorise ............................................................. (name of the international clearing system managing entity) and its Depository to collect and forward this certificate or a copy hereof, any attachments and any information relating to it, to the Portuguese authorities, including tax authorities. 6. This certificate is valid for a period of twelve months as from the date of signature. Place: ________________________ Date:___________________________ _____________________________ _______________________________ Authorised Signatory Name _______________________________ Title/Position ______________________________ _______________________________ Authorised Signatory Name ______________________________ Title/Position APPENDIX STATEMENT OF BENEFICIAL OWNERSHIP The undersigned beneficiary: Name: ........................................................................................................................................ Address:..................................................................................................................................... Tax ID number: ......................................................................................................................... Holding via the following financial intermediary: Name of the financial intermediary:.......................................................................................... .......................................................................................................................................................... Account number: ...................................................................................................................... The following securities: Common /ISIN code:................................................................................................................. Security name: ........................................................................................................................... Payment date: ............................................................................................................................ Nominal position:....................................................................................................................... Hereby declares that he/she/it is the beneficial owner of the above-mentioned securities and nominal position at the payment date ____/___/______; and Hereby declares that he/she/it is not liable to withholding tax, in accordance with the applicable legislation, indicated herein after (tick where applicable): Special Tax Regime approved by the Decree-Law no. 193/2005, 7 of November...................... Art. 97 of CIRC (Corporate Income Tax Code) Exemption from withholding tax ................... Art. 9 of CIRC State, Autonomous Regions, local authorities, their associations governed by public law and social security federations and institutions ........................................................... Art. 10 of CIRC General Public Interest Companies, Charities and other non-governmental social entities; exemption by Ministerial Regulation no. ............. , published in the Dirio da Repblica ......... Art. 16 of EBF (Tax Incentives Statute) Pension Funds and assimilated funds........................... Art. 21 of EBF Retirement Savings Funds (FPR), Education Savings Funds (FPE), Retirement and Education Savings Funds (FPR/E) ........................................................................................... Art. 23 of EBF Venture Capital Investment Funds ............................................................... Art. 26 of EBF Stock Savings Funds (FPA) ................................................................................ Other legislation (indicate which)................................................................................................... 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