Dividend Recipient Withholding Tax Form
Recipient Information
Full Name
Address
City
State/Province
Postal Code
Country
Tax Identification Number
Date of Birth (if individual)
Dividend Information
Payment Date
Dividend Amount
Type of Shares
Number of Shares
Tax Treaty Claim (if applicable)
Claiming Reduced Withholding?
Yes
No
Country of Tax Residence
Applicable Article/Paragraph
Certification & Signature
Signature
Date