Bijlage 1 Toepassing van het nieuwe Nederlands-Amerikaanse belastingverdrag van 18 december 1992, procedure voor het aannemelijk maken van verdragsgerechtigdheid, Triangular cases, centraal meldpunt voor eventuele vragen over de toepassing van het verdrag en halfjaarlijkse rapportage aan de Staten-Generaal

Toepassing van het nieuwe Nederlands-Amerikaanse belastingverdrag van 18 december 1992, procedure voor het aannemelijk maken van verdragsgerechtigdheid, Triangular cases, centraal meldpunt voor eventuele vragen over de toepassing van het verdrag en halfjaarlijkse rapportage aan de Staten-Generaal

This form (hereafter referred to as form ‘IB 93 USA’) may be filled in by the beneficial owner of items of income from US sources (in the following: ‘the applicant’) to demonstrate to the withholding agent (unless that agent has actual knowledge or reason to know otherwise) and to the US tax authorities that the conditions of article 26, and, if appropriate, those of article 12, paragraph 8, or article 13, paragraph 6, of the Convention of 18 December 1992 between the Netherlands and the United States of America for the avoidance of double taxation are satisfied and that the applicant is entitled to the benefits of the Convention. Before filling in this form, please read the instructions on the back of the fourth copy. Note: this form is intended only for residents of the Netherlands other than NB: The flow chart in annex I to form ‘IB 93 USA’, parts I -X is simplified version of the text of article 26. The flow chart in annex I to form ‘IB 93 USA’, part XI is based on the text of article 12, paragraph 8, and article 13, paragraph 6, of the Convention. Please consult the flow chart in annex I to form ‘IB 93 USA’ and the full text of the Convention when filling in this form. Any further questions can be addressed to the Inspector in whose jurisdiction the applicant is a resident. Data of the immediately preceding taxable year may be used when filling in this form, unless the applicant knows or has reason to know that changes will occur or have occurred in the facts and circumstances during the taxable year under consideration, which changes might affect the issuing of a statement for the taxable year under consideration. Please do not forget to fill in the list of estimated annual amounts of United States source passive income for which treaty benefits are claimed. This list is attached to the first copy of this form. 1. Full name, address, telephone number and ‘Landelijk Vast nummer’ (fiscal number) of applicant: .....................................................

• – individuals (article 26, paragraph 1, subparagraph a of the Convention)
• – the State or a political subdivision thereof or a local authority thereof (article 26, paragraph 1, subparagraph b of the Convention).
• a. o. The applicant does not meet one of the tests laid down in paragraphs 1 through 6 of article 26 (see question 4), but instead has obtained a favourable determination from the US competent authority for the application of the safety-valve provision laid down in article 26, paragraph 7, of the Convention. (See point 3 of the instructions on the back of the fourth copy) Go to question 3.
• b. o. A previous statement was issued for the applicant by the competent Dutch Inspector stating that the conditions of article 26 and, if appropriate, the conditions of article 12, paragraph 8, or article 13, paragraph 6, of the Convention are satisfied. Go to question 3.
• c. o. The applicant has not obtained a favourable determination from the US competent authority for the application of the safety-valve provision, nor was a previous statement issued for the applicant by the competent Dutch Inspector. Go to question 4. (please tick as appropriate)
• o No. In the situation where a previous statement was issued by the competent Dutch Inspector, please tick questions 4 and/or, if appropriate, question 5 of this form in the same manner as was done in the form requesting the issuing of the previous statement.
• o Yes. Go to question 4 and, if appropriate, 5 (See however point 4 and 5 of the instructions on the back of the fourth copy)
• a. o. not attributable to a permanent establishment of the applicant in a third state and thus not subject to tax in the United States of America, or
• b. o. attributable to a permanent establishment of the applicant in a third state and not subject to tax in the United States of America, since the applicant, in the case of interest income, satisfies the conditions of article 12, paragraph 8, and, in the case of royalty income, satisfies the conditions of article 13, paragraph 6, of the Convention, or
• c. o. attributable to a permanent establishment of the applicant in a third state and subject to tax in the United States of America at a rate of no more than 15 percent, since the applicant, in the case of interest income, does not satisfy the conditions of article 12, paragraph 8, respectively, in the case of royalty income, does not satisfy the conditions of article 13, paragraph 6, of the Convention.
• 0 Dividends Estimated annual amount
• 0 Under $ 100,00
• 0 $100,00 to $ 500,00
• 0 $ 500,000 to $ 1,000,000
• 0 over $ 1,000,000
• 0 Interest Estimated annual amount
• 0 Under $ 100,00
• 0 $100,00 to $ 500,00
• 0 $ 500,000 to $ 1,000,000
• 0 over $ 1,000,000
• 0 Royalties Estimated annual amount
• 0 Under $ 100,00
• 0 $100,00 to $ 500,00
• 0 $ 500,000 to $ 1,000,000
• 0 over $ 1,000,000
• – individuals (article 26, paragraph 1, subparagraph a of the Convention)
• – the State or a political subdivision thereof or a local authority thereof (article 26, paragraph 1, subparagraph b of the Convention).
• a. o. The applicant does not meet one of the tests laid down in paragraphs 1 through 6 of article 26 (see question 4), but instead has obtained a favourable determination from the US competent authority for the application of the safety-valve provision laid down in article 26, paragraph 7, of the Convention (See point 3 of the instructions on the back of the fourth copy) Go to question 3.
• b. o. A previous statement was issued for the applicant by the competent Dutch Inspector stating that the conditions of article 26 and, if appropriate, the conditions of article 12, paragraph 8, or article 13, paragraph 6, of the Convention are satisfied. Go to question 3.
• c. o. The applicant has not obtained a favourable determination from the US competent authority for the application of the safety-valve provision, nor was a previous statement issued for the applicant by the competent Dutch Inspector. Go to question 4. (please tick as appropriate)
• o No. In the situation where a previous statement was issued by the competent Dutch Inspector, please tick questions 4 and/or, if appropriate, question 5 of this form in the same manner as was done in the form requesting the issuing of the previous statement
• o Yes. Go to question 4 and, if appropriate, 5 (See however point 4 and 5 of the instructions on the back of the fourth copy)
• a. o. not attributable to a permanent establishment of the applicant in a third state and thus not subject to tax in the United States of America, or
• b. o. attributable to a permanent establishment of the applicant in a third state and not subject to tax in the United States of America, since the applicant, in the case of interest income, satisfies the conditions of article 12, paragraph 8, and, in the case of royalty income, satisfies the conditions of article 13, paragraph 6, of the Convention, or
• c. o. attributable to a permanent establishment of the applicant in a third state and subject to tax in the United States of America at a rate of no more than 15 percent, since the applicant, in the case of interest income, does not satisfy the conditions of article 12, paragraph 8, respectively, in the case of royalty income, does not satisfy the conditions of article 13, paragraph 6, of the Convention.
• – individuals (article 26, paragraph 1, subparagraph a of the Convention)
• – the State or a political subdivision thereof or a local authority thereof (article 26, paragraph 1, subparagraph b of the Convention).
• a. o. The applicant does not meet one of the tests laid down in paragraphs 1 through 6 of article 26 (see question 4), but instead has obtained a favourable determination from the US competent authority for the application of the safety-valve provision laid down in article 26, paragraph 7, of the Convention (See point 3 of the instructions on the back of the fourth copy) Go to question 3.
• b. o. A previous statement was issued for the applicant by the competent Dutch Inspector stating that the conditions of article 26 and, if appropriate, the conditions of article 12, paragraph 8, or article 13, paragraph 6, of the Convention are satisfied. Go to question 3.
• c. o. The applicant has not obtained a favourable determination from the US competent authority for the application of the safety-valve provision, nor was a previous statement issued for the applicant by the competent Dutch Inspector. Go to question 4. (please tick as appropriate)
• o No. In the situation where a previous statement was issued by the competent Dutch Inspector, please tick questions 4 and/or, if appropriate, question 5 of this form in the same manner as was done in the form requesting the issuing of the previous statement
• o Yes. Go to question 4 and, if appropriate, 5 (See however point 4 and 5 of the instructions on the back of the fourth copy)
• a. o. not attributable to a permanent establishment of the applicant in a third state and thus not subject to tax in the United States of America, or
• b. o. attributable to a permanent establishment of the applicant in a third state and not subject to tax in the United States of America, since the applicant, in the case of interest income, satisfies the conditions of article 12, paragraph 8, and, in the case of royalty income, satisfies the conditions of article 13, paragraph 6, of the Convention, or
• c. o. attributable to a permanent establishment of the applicant in a third state and subject to tax in the United States of America at a rate of no more than 15 percent, since the applicant, in the case of interest income, does not satisfy the conditions of article 12, paragraph 8, respectively, in the case of royalty income, does not satisfy the conditions of article 13, paragraph 6, of the Convention.
• – individuals (article 26, paragraph 1, subparagraph a of the Convention)
• – the State or a political subdivision thereof or a local authority thereof (article 26, paragraph 1, subparagraph b of the Convention).
• a. o. The applicant does not meet one of the tests laid down in paragraphs 1 through 6 of article 26 (see question 4), but instead has obtained a favourable determination from the US competent authority for the application of the safety-valve provision laid down in article 26, paragraph 7, of the Convention (See point 3 of the instructions on the back of the fourth copy) Go to question 3.
• b. o. A previous statement was issued for the applicant by the competent Dutch Inspector stating that the conditions of article 26 and, if appropriate, the conditions of article 12, paragraph 8, or article 13, paragraph 6, of the Convention are satisfied. Go to question 3.
• c. o. The applicant has not obtained a favourable determination from the US competent authority for the application of the safety-valve provision, nor was a previous statement issued for the applicant by the competent Dutch Inspector. Go to question 4. (please tick as appropriate)
• o No. In the situation where a previous statement was issued by the competent Dutch Inspector, please tick questions 4 and/or, if appropriate, question 5 of this form in the same manner as was done in the form requesting the issuing of the previous statement
• o Yes. Go to question 4 and, if appropriate, 5 (See however point 4 and 5 of the instructions on the back of the fourth copy)
• a. o. not attributable to a permanent establishment of the applicant in a third state and thus not subject to tax in the United States of America, or
• b. o. attributable to a permanent establishment of the applicant in a third state and not subject to tax in the United States of America, since the applicant, in the case of interest income, satisfies the conditions of article 12, paragraph 8, and, in the case of royalty income, satisfies the conditions of article 13, paragraph 6, of the Convention, or
• c. o. attributable to a permanent establishment of the applicant in a third state and subject to tax in the United States of America at a rate of no more than 15 percent, since the applicant, in the case of interest income, does not satisfy the conditions of article 12, paragraph 8, respectively, in the case of royalty income, does not satisfy the conditions of article 13, paragraph 6, of the Convention.