PART I. GENERAL — Internal Revenue Bulletin 2016-29

A. Did QI assume primary chapters 3 and 4 withholding responsibility for any calendar year covered by the certification period? Y/N

B. Did QI assume primary Form 1099 reporting and backup withholding responsibility for any calendar year covered by the certification period? Y/N

C. Is QI the Compliance QI for a consolidated compliance program? Y/N

If yes, provide the names and QI-EINs of the members of the consolidated compliance group. D. PAIs and partnerships and trusts to which QI applied the joint account or agency option during any time within the certification period:
The number of PAIs with whom QI has a PAI Agreement (if none enter 0). a. Provide the names and addresses of those PAIs. b. Each PAI has provided QI with a certification that it has maintained status as a certified deemed-compliant FFI (other

than a registered deemed-compliant Model 1 IGA FFI) for the certification period, as required under section 4.01 of the QI Agreement. Y/N c. Each PAI has provided QI with either (1) its information for inclusion in QI’s periodic review (as described in section

4.01(F) of the QI Agreement) or (2) a periodic certification as described under section 10.03 of the QI Agreement and a periodic review report as described under section 10.06 of the QI Agreement for the certification period. Y/N 2. The number of partnerships or trusts to which QI applies the agency option (if none enter 0). a. Provide the names and addresses of those partnerships or trusts. b. Each partnership or trust to which QI applies the agency option has provided QI with a certification that it has maintained

status as a certified deemed-compliant FFI (other than a registered deemed-compliant Model 1 IGA FFI), an ownerdocumented FFI with respect to QI, an NFFE, or an exempt beneficial owner, or that it is covered as an account that is excluded from the definition of financial account under Annex II of an applicable IGA or under Treas. Reg. § 1.1471–5(a), as required under section 4.06(A)(2) of the QI Agreement. Y/N c. Each partnership or trust to which QI applies the agency option pursuant to section 4.06 of the QI Agreement has

provided QI with either (1) its information for inclusion in QI’s periodic review (as described in section 4.06(A)(5) of the QI Agreement) or (2) a periodic certification required under section 10.03 of the QI Agreement and a periodic review report as required under section 10.06 of the QI Agreement for the certification period. Y/N 3. The number of partnerships or trusts to which QI applies the joint account option (if none enter 0). a. Provide the names and addresses of those partnerships or trusts. b. Each partnership or trust to which QI applies the joint account option has provided QI with a certification that it has

maintained status as a certified deemed-compliant FFI (other than a registered deemed-compliant Model 1 IGA FFI), an owner-documented FFI with respect to QI, an exempt beneficial owner, or an NFFE or that it is covered as an account that is excluded from the definition of financial account under Annex II of an applicable IGA or under Treas. Reg. § 1.1471–5(a), as required under section 4.05(A)(1) of the QI Agreement. Y/N

July 18, 2016 118 Bulletin No. 2016–29

PART II: CERTIFICATION OF INTERNAL CONTROLS AND GENERAL INFORMATION —To be Completed by All QIs. Complete Either A (Certification of Effective Internal Controls) or B (Qualified Certification).

A. Certification of Effective Internal Controls

If the responsible officer has identified: (1) an event of default or (2) a material failure that QI has not corrected as of the date of this certification (or such an event of default or material failure has otherwise been identified), QI cannot make the certification of effective internal controls under this Part A and must make the qualified certification under Part B, below.

The responsible officer certifies to the following, check each statement to confirm:

QI has established a compliance program that meets the requirements described in section 10.02(A) or 10.02(B) (if applicable) of the QI Agreement that is in effect as of the date of the certification and during the certification period.
Based on the information known (or information that reasonably should have been known) to the responsible officer, including the findings of any procedure, process, or review undertaken in preparation for the responsible officer’s certification of internal controls, QI maintains effective internal controls over its documentation, withholding, and reporting obligations under the QI Agreement and according to its applicable FATCA requirements, with respect to accounts for which it acts as a qualified intermediary, and, if QI is acting as a QDD, it maintains effective internal controls over its computation and tax obligations under the QI Agreement and the regulations under section 871(m).
Based on the information known (or information that reasonably should have been known) to the responsible officer, including the findings of any procedure, process, or review undertaken in preparation for the responsible officer’s certification of internal controls, there are no material failures, as defined in section 10.03(D) of the QI Agreement, or, if there are any material failures, they have been corrected as of the date of this certification, and such failures are identified as part of this certification as well as the actions taken to remediate them and to prevent their reoccurrence by the date of this certification. See Part II.D.3.A.
With respect to any failure to withhold, deposit, or report to the extent required under the QI Agreement, or, with respect to QI that is acting as a QDD, any failure to pay its QDD tax liability, QI has corrected such failure by paying any taxes due (including interest and penalties) and filing the appropriate return (or amended return).
All PAIs of QI and partnerships and trusts to which QI applies the agency option have either (a) provided (or will provide, to the extent QI does not obtain a waiver under section 10.07 of the QI Agreement) documentation and other necessary information for inclusion in the QI’s periodic review or (b) provided the responsible officer of QI with a certification of effective internal controls meeting the requirements of section 10.03(A) of the QI Agreement and have represented to QI that there are no material failures, as defined in section 10.03(D) of the QI Agreement, or, if there are such failures, they have been corrected as of the time of this certification, and the PAIs, partnerships, or trusts have disclosed any such failures to QI together with the actions taken by the PAI, partnership, or trust to remediate such failures.
QI’s policies, procedures, and processes are applied consistently to all branches covered by the QI Agreement (except as otherwise required by a jurisdiction’s AML/KYC procedures, as applicable).
If QI is acting as a QDD, it has acted as a QDD for all payments with respect to potential section 871(m) transactions and underlying securities for which it is required to act as a QDD and no other transactions or underlying securities.
If QI is acting as a QI and has assumed primary withholding responsibility with respect to payments of substitute interest (as described in section 3.03(A) of the QI Agreement), QI has assumed primary withholding responsibility for all such payments covered by the QI Agreement.
A periodic review was conducted for the certification period in accordance with section 10.04 of the QI Agreement, and the results of such review are reported to the extent required in sections 10.05 and 10.06 of the QI Agreement.

B. Qualified Certification

If the responsible officer has identified an event of default or a material failure that QI has not corrected as of the date of this certification, check the applicable statements to confirm:

The responsible officer (or designee) has identified an event of default, as defined in section 11.06 of the QI Agreement, or has determined that, as of the date of the certification, there are one or more material failures as defined in section 10.03(D) of the QI Agreement with respect to QI’s compliance, its PAI’s compliance, or the compliance of a partnership or trust to which QI applies the agency option and that appropriate actions will be taken to prevent such failures from reoccurring.
With respect to any failure to withhold, deposit, or report to the extent required under the QI Agreement, or with respect to QI that is acting as a QDD, a failure to pay its QDD tax liability, QI will correct such failure by paying any taxes due (including interest and penalties) and filing the appropriate return (or amended return).
The responsible officer (or an officer of the PAI or partnership or trust to which QI applies the agency option if the PAI or partnership or trust performs its own periodic review) will respond to any notice of default (if applicable) or will provide (either directly or through QI) to the IRS, to the extent requested, a description of each material failure and a written plan to correct each such failure

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C. Amended Form 1042

QI filed an amended Form 1042 to report additional tax liability based on the results of the periodic review or the findings of any other procedure, process, or review undertaken by the responsible officer in preparation for his or her certification of internal controls. Y/N a. If Yes, QI used a projection method in determining the amount of the additional tax liability. Y/N Note: If QI is acting as a QDD, it may not use a projection method in determining the amount of any additional QDD tax liability.

i. If Yes, QI used the safe harbor projection method under Appendix II to the QI Agreement. Y/N ii. If No, describe the projection method used.

D. Material Failures or Event of Default

Check the applicable statements to confirm. If QI is a compliance QI and identifies a material failure or event of default, it should also indicate which QI in the consolidated compliance group is associated with the material failure or event of default.

The responsible officer has determined that as of the date of the review, there are no material failures with respect to QI’s compliance with the QI Agreement.
The responsible officer has determined that as of the date of the review, there are one or more material failures with respect to QI’s compliance with the QI Agreement and that appropriate actions have been or will be taken to prevent such failures from reoccurring. a. The following material failures were identified:

i. QI’s establishment of, for financial statement purposes, a tax reserve or provision for a potential future tax liability

related to QI’s failure to comply with the QI Agreement, including its FATCA requirements as a participating FFI, registered deemed-compliant FFI, or registered deemed-compliant Model 1 IGA FFI, or, in the case of direct reporting NFFE, its requirements under Treas. Reg. § 1.1472–1(c)(3), and with respect to QI that is acting as a QDD, failure to satisfy its QDD tax liability and its obligations pursuant to section 871(m) and the regulations under that section. ii. QI’s failure to establish written policies, procedures, or systems sufficient for the relevant personnel of QI to take actions

consistent with QI’s obligations under the QI Agreement, including its FATCA requirements as a participating FFI, registered deemed-compliant FFI, or registered deemed-compliant Model 1 IGA FFI, or, in the case of a direct reporting NFFE, its requirements under Treas. Reg. § 1.1472–1(c)(3), or if QI is acting as a QDD, its obligations as a QDD under the QI Agreement and pursuant to section 871(m) and the regulations under that section. iii. A criminal or civil penalty or sanction imposed on QI (or any branch or office thereof) by a regulator or other

governmental authority or agency with oversight over QI’s compliance with AML/KYC procedures to which QI (or any branch or office thereof) is subject and that is imposed due to QI’s failure to properly identify account holders under the requirements of those procedures. iv. A finding (including a finding noted in the periodic review report described in section 10.06 of the QI Agreement) that,

for one or more years covered by the QI Agreement, QI failed to:

Withhold an amount that QI was required to withhold under chapter 3 or 4 or under section 3406 as required under section 3 of the QI Agreement or, if QI is acting as a QDD, failing to timely pay its QDD tax liability;
Provide information sufficient for another withholding agent to perform withholding and reporting to the extent required when QI does not assume primary chapters 3 and 4 withholding responsibility or primary Form 1099 reporting and backup withholding responsibility;
Provide allocation information as described in section 6.03(D) of the QI Agreement (regarding U.S. non-exempt recipient account holders) by January 15, as required by that section when QI applies the alternative withholding rate pool procedures;
Make deposits in the time and manner required by section 3.08 of the QI Agreement or make adequate deposits to satisfy its withholding obligations or, if QI is acting as a QDD, satisfy its QDD tax liability, taking into account the procedures under section 9 of the QI Agreement
Report or report accurately on Forms 1099 as required under section 8.06 of the QI Agreement or provide information to the extent QI does not assume primary Form 1099 reporting and backup withholding responsibilities;
Report or report accurately on Forms 1042 and 1042–S under sections 7 and 8 of the QI Agreement or, if QI is acting as a QDD, obtain any necessary waiver from reporting or maintain the name, address, and TIN of a significant number of U.S. non-exempt recipients to whom the QDD made a payment that otherwise would be a qualifying dividend equivalent offsetting payment but for the limitation in section 2.70(B) of the QI Agreement ; or
Report or report accurately on Form 8966 under sections 8.04 and 8.05 of the QI Agreement. v. Other (include a detailed explanation).

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The material failure identified in the review has been corrected by the time of this certification. Y/N/NA a. If yes, describe the steps taken to correct the material failure. b. If no, describe the proposed steps to be taken to correct the material failure and the time frame for completing such steps.
Did any PAI of QI inform QI that it has had a material failure with respect to its agreement with QI? Y/N/NA a. If yes, provide name of PAI and, based on the information provided by PAI, describe the steps taken to correct the material

failure or the proposed steps to be taken to correct the material failure and the timeframe for completing such steps. 5. Did any partnerships or trusts to which QI applies the agency and/or joint account option inform QI that it has had a material failure with respect to its obligations as described in the QI Agreement? Y/N/NA a. If yes, provide name of the partnership or trust and, based on the information provided by the partnership or trust, describe

the steps taken to correct the material failure or the proposed steps to be taken to correct the material failure and the timeframe for completing such steps. 6. An event of default as defined in section 11.06 of the QI Agreement has been identified. Y/N a. If yes, identify the event of default:

i. QI failed to implement adequate procedures, accounting systems, and internal controls to ensure compliance with

the QI Agreement; ii. QI underwithheld a material amount of tax that QI was required to withhold under chapter 3 or 4 or backup withhold

under section 3406 and failed to correct the underwithholding or to file an amended Form 1042 or 945 reporting, and paying, the appropriate tax; iii. QI made excessive refund claims;

iv. Documentation described in section 5 of the QI Agreement was lacking, incorrect, or unreliable for a significant

number of direct account holders; v. QI filed Forms 945, 1042, 1042–S, 1099, or 8966 that are materially incorrect or fraudulent; vi. If QI is an FFI, QI failed to materially comply with its FATCA requirements as a participating FFI, registered

deemed-compliant FFI, or registered deemed-compliant Model 1 IGA FFI; vii. If QI is an NFFE acting as a QI on behalf of its shareholders, QI failed to materially comply with its requirements

as a direct reporting NFFE under § 1.1472–1(c)(3); or if QI is a sponsoring entity, QI failed to materially comply with the due diligence, withholding, reporting, and compliance requirements of a sponsoring entity; viii. QI failed to materially comply with the requirements of a nonqualified intermediary under chapters 3 and 61, and

section 3406 with respect to any account for which QI does not act as a QI; ix. QI failed to perform a periodic review when required or document the findings of such review in a written report;

x. QI failed to cooperate with the IRS on its compliance review described in section 10.08 of the QI Agreement; xi. QI failed to inform the IRS of any change in the know-your-customer rules described in any Attachment to the QI

Agreement within 90 days of the change becoming effective; xii. QI failed to inform the IRS within 90 days of any significant change in its business practices to the extent that change

affects QI’s obligations under the QI Agreement; xiii. QI failed to inform the IRS of any PAI of QI, as described in section 4 of the QI Agreement; xiv. QI failed to cure a material failure identified in the qualified certification described in section 10.03 of the QI

Agreement or identified by the IRS; xv. QI made any fraudulent statement or a misrepresentation of material fact with regard to the QI Agreement to the IRS,

a withholding agent, or QI’s reviewer; xvi. The IRS determined that QI’s reviewer is not sufficiently independent, as described in the QI Agreement, to

adequately perform its review function, and QI failed to arrange for a periodic review conducted by a reviewer approved by the IRS; xvii. An intermediary with which QI has a PAI agreement was in default with that agreement and QI failed to terminate

that agreement within the time period specified in section 4.04 of the QI Agreement; xviii. A partnership or trust to which QI applied the agency option was in default with that agreement and QI failed to

terminate that agreement within the time period specified in section 4.06 of the QI Agreement; xix. If QI is acting as a QDD, QI failed to timely pay a material amount of its QDD tax liability and failed to correct the

underpayment and pay the appropriate tax amount; or xx. Other (please describe).

E. Significant Change in Circumstances

Check the applicable statements to confirm.

For the most recent certification period, the periodic review has not identified any significant change in circumstances, as described in section 11.04(A), (D), (E), or (J) of the QI Agreement.
For the most recent certification period, the periodic review has identified the following significant change(s) in circumstances:

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a. An acquisition of all, or substantially all, of QI’s assets in any transaction in which QI is not the surviving legal entity. b. A material change in the know-your-customer rules and procedures set forth in any attachment to the QI Agreement. c. A significant change in QI’s business practices that affects QI’s ability to meet its obligations under the QI Agreement. d. If QI is acting as a QDD, QI ceases to qualify as an eligible entity, including as a result of a change in its business or

regulatory status. e. Other. 3. Describe any significant changes in circumstances identified in Question 2 (and, if 2.d is selected, include the date on which the QI ceased to qualify as an eligible entity).

F. Chapter 4 Status

Complete the applicable section and check the applicable statement to confirm.

Participating FFIs

For the most recent certification period under the QI Agreement, QI (or a branch of QI) has obtained status as a participating FFI and made the following certification of compliance with respect to its FFI agreement for the most recent certification period under the FFI agreement (check one). Note: You may only check N/A if, during the certification period, your chapter 4 status changed from one of the other applicable chapter 4 statuses to participating FFI. a. Certification of Effective Internal Controls b. Qualified Certification c. N/A

Registered Deemed-Compliant FFIs

For the most recent certification period under the QI Agreement, QI certified as required under Treas. Reg. § 1.1471– 5(f)(1)(ii)(B) or Annex II of an applicable Model 2 IGA that it has satisfied the requirements for the deemed-compliant FFI status claimed.

Registered Deemed-Compliant Model 1 IGA FFIs

For the most recent certification period under the QI Agreement, QI (or a branch of QI) has been resident in or organized under the laws of a jurisdiction that has in place a Model 1 IGA with the United States (or in the case of a branch of QI, the branch operates in the jurisdiction) and has met the requirements under the IGA to be treated as a deemed-compliant FFI.

Direct Reporting NFFEs

For the most recent certification period under the QI Agreement, QI has been a direct reporting NFFE and has met the requirements of Treas. Reg. § 1.1472–1(c)(3).